This site allows you to request a new Mentor customer account or request updates to your existing Mentor customer account. Please complete the form below. Requests are normally completed within 72 business hours. If the information supplied is incomplete or found to be incorrect, this may delay processing of the application and could affect prompt delivery of products or services. Please note that Mentor reserves the right in its sole discretion to reject any requests for a new customer account or updates to an existing customer account.
Please contact [email protected] if you have any questions.
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Explain Your Request
In as much detail as possible, please explain your request *
You must provide an explanation.
e.g., I need to create a new billing account, I need to reactivate my account, I need to change my ship-to address, I need to apply for terms/credit, etc.
Please check the appropriate option(s) to help us fully understand your request. *
You must select at least one option.
Business Information
Sales Representative Name
Letters and spaces only.
Letters and spaces only.
Tax Exempt
If applicable, please attach a copy of your state tax exempt certificate.
Upload or drag files here.
You must upload a copy of your state tax exempt certificate.
Only files of type.doc, .pdf, .xls, or .xls are accepted..
State where incorporated *
You must enter a State.
Subsidiary of
Account Payable Contact Name *
You must enter a first name.
Letters and spaces only.
You must enter a last name.
Letters and spaces only.
Account Payable Contact Email *
You must enter an email address.
Invalid email format.
Account Payable Contact Phone *
You must enter contact phone.
Phone must be in format of (XXX) XXX-XXXX
Billing Account Information
Mentor Billing Account Number
Digits only.
New Mentor Billing Account Name
You must enter a New Mentor Billing Account Name.
Billing Account Address *
You must enter a Billing Address.
Letters, digits, and spaces only.
Letters, digits, and spaces only.
You must enter a Billing City.
Letters and spaces only.
You must enter a Billing State.
You must enter a Billing Zip Code.
5 digits only.
Phone *
You must enter a Billing Phone.
Phone must be in format of (XXX) XXX-XXXX
Fax
Fax must be in format of (XXX) XXX-XXXX
Website
Website must be a valid URL
Shipping Account Information
Mentor Shipping Account Number
New Mentor Shipping Account Name
You must enter a New Mentor Shipping Account Name.
Confirmation
Sign this form by entering your email address and check the below box. Your signature on this form confirms your authorization for Mentor Worldwide LLC to keep this information on file. By signing this form you certify that all information provided is complete and accurate.
Owner/Partner/Officer Email *
You must enter an Email Address.
Invalid email format.
*
You must give permission to Mentor to run your credit.
Please note that Mentor reserves the right in its sole discretion to reject this credit application and to negate any obligation to proceed with the sale of any Mentor products. In submitting this application for credit, Buyer authorizes Mentor to investigate Buyer’s credit record. Mentor reserves the right to limit the amount of credit extended under this account or terminate the account upon 30 days written notice.