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Distributor Application Form

Date:

241 Heritage Drive
P.O. Box 758 • Tiffin, Ohio 44883
ph: 419-448-6622 • 1-800-332-5081
fax: 419-448-6627 • www.qt2.com

Company Name:

Business Phone:

Street (Not P.O. Box #):

FAX:

P.O. Box (If applicable for billing purposes):

City:

State:

Zip:

Ship To (If different):

Type of Organization:

Corporation Partnership Individual Proprietorship

If Incorporated, In Which State

Resale Tax #

Years in Business

Annual Sales

Previous Business Name (if any)

Purchase Order # Required?

Yes No

Principal Owners/Officers & Titles	Address & Phone

Trade References:

1.	Firm Name:	Email :
	Address:	Phone #:
	City, State, Zip	Account #:

2.	Firm Name:	Email:
	Address:	Phone #:
	City, State, Zip	Account #:

3.	Firm Name:	Email:
	Address:	Phone #:
	City, State, Zip	Account #:

Bank Reference:

Principal Bank:

Phone #:

Branch:

Account #:

Contact:

Contact Information:

Accounts Payable Contact


Name	Phone	E-Mail

Sales/Order Contacts


Name/Position	Phone	E-Mail

Name/Position	Phone	E-Mail

TERMS AND CONDITIONS:
1. Prepayment may be required until this application is processed and approved.
2. Canceled orders are subject to fees incurred and a $20 cancellation fee.
3. All open account invoices have 1% 20, net 30 terms unless otherwise specified.
4. Discount of 1% does not apply to CC payments or freight.
5. A $40 surcharge will be billed for all returned checks regardless of the reason.
6. A one-and-one-half (1.5%) monthly interest charge will be applied to any unpaid balance.
7. Applicant is responsible for all legal and collection fees to recover funds that are 60 days or more delinquent.
8. Applicant authorizes and grants QT2 to investigate trade and bank reference information provided.
9. The information provided by me on this application is true and accurate to the best of my knowledge.

The information given is warranted to be true and Applicant authorizes Grantor to investigate said information.

Signature of Owner/Partner or Officer:

Title:

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