Distributor Application

Company Name:________________________________________________________________

Street Address:_________________________________________________________________

City:_________________________________State:______________ Zip:___________________

Contact(s)

Sales:______________________________________Phone:____________Fax:______________

Purchasing:__________________________________Phone:____________Fax:______________

Payables:____________________________________Phone:____________Fax:______________

Credit References

Company____________________Contact:________________Phone:___________Fax:_________

Company____________________Contact:________________Phone:___________Fax:_________

Company____________________Contact:________________Phone:___________Fax:_________

 

Signature:_____________________________________________ Date:_____________

FAX TO 828-645-3671

Quality America, Inc
PO Box 8787 Asheville, N.C. 28814
Ph: 828-645-3661