Customer Account Update Form

Complete Sections 1 and 2 to create an account with Circuit Technology Center.
Complete Sections 1 and 3 to request ACH (Automated Clearing House) bank details.
Complete Sections 1 and 4 to provide a credit card or to update your credit card details.

1. FORM COMPLETED BY

Name *

Email *

Phone *

Job Title *

* Indicated required field.

2. YOUR COMPANY INFORMATION

Business Name

Business Website Address

Business Address

Tax ID

DUNS

Accounts Payable Contact Name

Accounts Payable Contact Job Title

Accounts Payable Contact Phone

Accounts Payable Contact Email

3. ACH BANKING INFORMATION

ACH Bank Request - Check to request ACH bank account/routing number details for Circuit Technology Center. Details will be sent to the email address provided in section 1.

4. CREDIT CARD DATA

Name On Card

Card Number

ZIP/Postal Code

Card Type

Expiration Date

Security Code

5. FORM SECURITY & SUBMIT

Our forms are hosted with Amazon Web Services in the United States and use an industry-leading web application firewall. Data and uploads are encrypted at rest using AES-256 block-level storage encryption. We use a minimum of TLS 1.2 to encrypt network traffic between your web browser and our forms.

Send Documents *

Choose File No file chosen

Notes/Questions/Requests

Product Type
Assemblies Bare PCBs Other

Quantity

Delivery Schedule Request
3 Weeks 2 Weeks 1 Week
2-3 Days 1 Day

Security Check

* You may upload PDFs and other file types (max 4 MB each). For multiple files, zip them or send to info@circuitrework.com

Form Security
Our forms run on AWS with an industry-leading firewall. Data is encrypted at rest with AES-256 and in transit using TLS 1.2+.