Wholesale Application

1Business information

2Business Owner

3Trade References

Business Owners Name*
First Last
Email*
Home Address*
Street Address Address Line 2 City Province Postal Code
Phone*
Cell Phone
Bank and reference info not required if account is prepaid.
Bank
Bank Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Company name
Name
First Last
Email
Phone
Fax
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Company name
Name
First Last
Email
Phone
Fax
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Company name
Name
First Last
Email
Phone
Fax
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Consent*
I agree to the terms
I hereby authorize Quanta Distribution Inc. to use the information on this credit application in reference to opening a charge account for the above named company applying.
Quanta Distribution Inc. may cancel this charge account and any privileges at any time without notice but it is understood and agreed that this does not relieve the above named company for purchases when due. It is understood and agreed that a service charge of 1 ½ % per month (18% annual) will be charged on all past due accounts.
Signature*
Name*
First Last