Please fill out this form to become a reseller.

Company Information
Company Name: *

Business Name:

State Resale #:

Contact Name:*

Email Address:*

Daytime Telephone:*

Fax #:

Address:

City:

State/Province:

Postal Code:

Country:


Company Owned Real Property:
No Yes
Complete Addres: (If different from above)
Business Classification:

How Long in Business?(yrs)

Federal ID #:*

D&B#:

Type of Business:

Incorporated in What State?

If less than one year, previous address:


Bank Reference
Company Bank:

Account#:

Bank Branch:

Contact Person:

Address:

City/State:

Phone#:

 

Trade References

Supplier Name:

Phone #:

Fax:

Contact Name:

Address:

City/State/Zip:

 

Supplier Name:

Phone #:

Fax:

Contact Name:

Address:

City/State/Zip:

 

Supplier Name:

Phone #:

Fax:

Contact Name:

Address:

City/State/Zip:

 

Authorized People to Purchase:

Purchase Order(s) Required:
No Yes

Request Credit Desired:

Estimated Monthly Purchases:

 

Principals of Company
Name:

Social Security #:

Title:

Address:

Own Rent

 
Name:

Social Security #:

 Title:

Address:

Own Rent

 

Brief Survey

How did you hear about us?
Other:

Product Interest:
Category 5 & 6 Cisco Cables Displays/Video DataLine Surges
DataSwitches Digital Signage Fiber Optics Fibre Channel
Firewire Internal PC Cables KVM Switches Apple Cable & Accessories
Multimedia A/V Parallel Peripheral Sharing PC Accessories & Toolkits
Power Protection SCSI Serial USB 2.0/3.0
Other:

 

Default Agreement - Corporation

In the event payment is not made and this account is referred for collection, I/WE will pay the cost of collection equal to a minimum amount of twenty-five percent of the principal amount except limited by local law. I/WE understand interest on any unpaid balance will be charged at the highest rate authorized by law. If suit or action by an attorney is instituted, I/WE promise to pay reasonable attorney fees in said suit or action. It is understood that all billing of accounts receivables & credit are processed through head-quarters in Wayne County, MI. It is understood that in the event of a suit or action, it is understood that Wayne County, MI, at the option of QVS is the venue for litigation. I/WE understand that I/WE are waiving our right to litigate outside of Wayne County, MI.

Initials: Date:

 

Proprietor/Owner

I/WE undersigned agree to guarantee payment of all sums due and owing. I/WE understand that venue is as stated above and this continuing guarantee shall not be revoked except by 90 days advance written notice to QVS.

Initials: Date:

 

If you are currently working with a QVS Account Manager, please specify on the space below.

Sales Representative: