Vendor Application

Contact Name: ______________________________________________

Company Name: ____________________________________________

Address: __________________________________________________

City, State Zip: _____________________________________________

Phone - Voice: Fax: _________________________________________

E-Mail: __________________________________________________

1. Does your company currently market computer software? Yes No

If yes, what brands? ___________________________________________

___________________________________________________________

___________________________________________________________

2. Does your company sell computer hardware? Yes No

3. What other products does your company sell? ______________________

___________________________________________________________

___________________________________________________________

4. Please list current marketing personel that may place orders for your company.

___________________________________________________________

___________________________________________________________

___________________________________________________________

Credit Card Type: ____ Visa ____ MasterCard ____ AMEX

Card Number: ___________ ____________ ____________ ___________

Expiration: _____ / _____

Name on card: _______________________________________________

I authorize the above credit card to be used for transactions with Quick Quote.

Signature: ___________________________________________________

Fax or Mail this completed form to:

Quick Quote

18975 Mesa Drive

Villa Park, CA 92861

Fax: (714) 283-8537