Name: 
	

	

	

	
Company: 
	

	

	

	
Address1: 
	

	

	

	
Address2: 
	

	

	

	
 City: 
	
 
	

	

	
State: 
	

              California
              Alabama 
              Alaska 
              Arizona 
              Arkansas 
              California 
              Colorado 
              Connecticut 
              Delaware 
              District of Columbia 
              Florida 
              Georgia 
              Hawaii 
              Idaho 
              Illinois 
              Indiana 
              Iowa 
              Kansas 
              Kentucky 
              Louisiana 
              Maine 
              Maryland 
              Massachusetts 
              Michigan 
              Minnesota 
              Mississippi 
              Missouri 
              Montana 
              Nebraska 
              Nevada 
              New Hampshire 
              New Jersey 
              New Mexico 
              New York 
              North Carolina 
              North Dakota 
              Ohio 
              Oklahoma 
              Oregon 
              Pennsylvania 
              Rhode Island 
              South Carolina 
              South Dakota 
              Tennessee 
              Texas 
              Utah 
              Vermont 
              Virginia 
              Washington 
              West Virginia 
              Wisconsin 
              Wyoming 
                      Zip Code: 
	

	

	
Country: 
	

	

	

	
E-Mail: 
	

	

	

	
Phone: 
	
(  ) 
	

	

	
FAX: 
	
(  ) 
	
	

	
 Years In Business: 
	

	
	

	
 Industry Type: 
	

	
	

	
 Type Of Business: 
	
Example: Manufacturing, Consulting, R & D Lab, etc,..
	


1.  Are MSDS(s) being received and filed for all chemicals used
    at your facility?
            Yes  No

2.  Name of person to receive MSDS(s): 
        

3.  Name of Technical contact (T.D., Chemist, etc.): 
        

4.  Are your facility's manufacturing permits up to date?  Are 
    copies available?
            Yes  No

5.  Are recommended protective systems, including up-to-code
    sprinklers and local ventilation, in place and functioning at
    your facility?
            Yes  No

6.  Does your company have a written safety plan?  Is it displayed
    in an area accessable to all employees?
            Yes  No

7.  Has your company ever experienced any incidents (spills, fires,
    explosions, releases) that were reportable to authorities?
            Yes  No
    If Yes, please explain:
        

8.  If commercial quantities of product are used in your facility,
    would your organization desire a product safety presentation.
            Yes  No

     Agreement:
        USER AGREEMENT:
You agree to have answered all questions truthfully and without deception and ambiguity.

You also represent that you have read and understand all questions answered.

As a member in good standing of the National Association of Chemical Distributors, TCR Industries is responsible for providing care in the sale and distribution of chemical raw materials. Thus, our primary goal in collecting identifiable information is to verify that you and your organization has the capabilities to properly and with full responsibility handle all material supplied by us.
    ____________________________________

PRIVACY POLICY:
Data Security: We have in place physical, electronic and managerial procedures to protect the information we collect online. However, as effective as these measures are, no security system is impenetrable. We cannot guarantee that the information you supply will not be intercepted while being transmitted to us over the internet. 
    ____________________________________

By submitting your information, you agree to have read all of the USER AGREEMENT and PRIVACY POLICY.  This Agreement shall be governed by the laws of the United States.


	 I've read and Accept the Agreement
	 I Do Not Accept