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:    Coporation    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: Fax #:
  Address: Phone #:
  City, State, Zip Account #:
2. Firm Name: Fax #:
  Address: Phone #:
  City, State, Zip Account #:
3. Firm Name: Fax #:
  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 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: