Credit Application

Application for Open Credit Account

Thank you for your interest in doing business with Q-mation, Inc. Please complete the application below to be considered for an open credit account.

Company Name:(Required)

Company Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Company Phone Number(Required)

Company Fax Number

Accounts Payable Contact Name:(Required)

First Last

Accounts Payable Phone Number(Required)

Accounts Payable Email Address(Required)

Billing(Required)

Does your company accept invoicing by email or via web portal?

Yes

Please enter either the email address (or) web portal URL (web address) for invoice submissions:

Billing Email Address (or) Web Portal URL(Required)

Vendor Setup(Required)

Does your company have a vendor setup form you would like us to complete and return to you?

Yes

Vendor Setup Form(Required)

Please upload your vendor setup form that you would like us to complete and return.

Drop files here or

Max. file size: 50 MB.

Credit Limit Amount Requested(Required)

Tax Exempt Status(Required)

Are your purchases tax exempt?

Yes

Tax Exemption Documents(Required)

Please upload all applicable tax exemption documents, including certifications, direct pay permits, or resale certificates.

Drop files here or

Max. file size: 50 MB.

Trade References(Required)

I have a document listing my trade references I'd like to upload.

I'd like to enter my trade references manually.

Upload Trade References(Required)

Upload your trade reference document.

Drop files here or

Max. file size: 50 MB.

Enter Trade References

Please list four (4) trade references in the fields provided below:

Trade Reference 1

Company Name(Required)

Company Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Company Phone Number(Required)

Company Fax Number

Company Email(Required)

Trade Reference 2

Company Name(Required)

Company Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Company Phone Number(Required)

Company Fax Number

Company Email(Required)

Trade Reference 3

Company Name(Required)

Company Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Company Phone Number(Required)

Company Fax Number

Company Email(Required)

Trade Reference 4

Company Name(Required)

Company Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Company Phone Number(Required)

Company Fax Number

Company Email(Required)

Your Name(Required)

Please enter the contact information of the individual completing this application.

First Last

Your Email(Required)

Your Contact Phone Number(Required)

Q-mation Contact

Please enter the name of your sales contact at Q-mation.

First Last

Comments

This field is for validation purposes and should be left unchanged.