QPL Electronics Distributors

Application for Credit

Instructions:
Complete the online application form below. After you press the SUBMIT button, you will be able to print out a copy of the application and fax it to us.

Company Information

Company Name:
Contact E-mail:
Contact Phone:
Accounts Payable Phone:
Accounts Payable FAX:
Contact Fax:
Line of Business or Profession:
# of Employees:
Years Established:
Tax Exempt or Federal ID #:
Please fax a copy of your tax exempt form to (978) 671-0006.

Billing Address

Address:

City:
State/Province:
Postal Code:
Country:

Company Ownership

Type (required):	Individual Partnership Corporation
Principals (Name, Title):

Credit References (Please furnish complete information)

#1 - Company Name:
Address:
City, State, Zip:
Phone:
Fax:

#2 - Company Name:
Address:
City, State, Zip:
Phone:
Fax:

#3 - Company Name:
Address:
City, State, Zip:
Phone:
Fax:

#4 - Company Name:
Address:
City, State, Zip:
Phone:
Fax:

Bank References (Please furnish complete information)

Bank Name:
Address:
City, State, Zip:
Contact:
Account #:
Phone:
Fax:

May we fax original invoice to you for payment? Yes No

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