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