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New Account Setup 		   
 

Qorpak requires that the following New Customer Account form to be completed prior to ordering. 

If Net 30 credit terms are desired, a Credit Application must also be signed and submitted via fax/mail.

*Fields marked with an asterisk are required fields

 
Basic Information
  
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*Customer Type:
  
 
Billing Address  
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*Company Name:
  
*Street:
  
*City:
  
*State:
  

*Zip:

  
*Country:
  
*Phone:
  
Fax:
  
E-mail:
  
 
Shipping Address  

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  Check box if Shipping Information is the same as the Billing Address
Company Name:
  
Street:
  
City:
  
State:
  
Zip:
  
Phone:
  
Fax:
  
 
Ordering and Billing Contact  
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Purchasing Contact:
  
Phone:
 
  
(If different than Billing Address phone)
  Check box if Ordering Phone number is the same as Billing Phone number
 
Accounts Payable Contact:
  
Phone:
  
(If different than Billing Address phone)
  Check box if Accounts Payable Contact is the same as Purchasing Contact
 
Invoicing Requirements  
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*Number of invoice copies requested:
  
 
Sales Tax Information  
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*Taxable?:
  
    If NO, Please fill in STATE and EXEMPTION #
State:
  
Exemption Number:
  
 
  If non-taxable and in CA, FL, IL, IN, MA, MD, NC, NJ, NY, OH, PA, SC, TN, TX, WI, or WV, please submit exemption certificate via mail or fax (412-257-3001).
 
  THIS SALES TAX INFORMATION IS FOR INITIAL ORDERS ONLY. ALL STATES REQUIRE BY LAW THAT PROPERLY COMPLETED EXEMPTION CERTIFICATES MUST BE ON FILE WITHIN 60 DAYS OF INVOICE. PLEASE SUBMIT ALL FORMS PROMPTLY TO RETAIN TAX EXEMPT STATUS.
 
Shipping Instructions  
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Preferred Carrier:
  
  UPS will not accept responsibility of breakage of glass shipments
 
Payment: For Net 30 Terms  
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For the Net 30 Days option, please submit a Credit Application.

  Check box if you are a submitting a Credit Application

Click Here for the Credit Application. Then complete the form and send back via fax or mail to Qorpak. (Fax: 412-257-3001)

(Adobe Acrobat Reader is required in order to view/print Credit Application)
 
Payment: Credit Card   top of page
     
    Check box if Credit Card is your preferred method of payment
     
    If payment by Credit Card is preferred, please submit Credit Card information when placing your order
     
MINIMUM ORDER REQUIREMENT IS $50.00.
$175.00 OR MANUFACTURERS MINIMUM ORDER REQUIREMENTS APPLY TO NON-STOCK ITEMS.
THERE IS A RESTOCKING CHARGE ON ITEMS RETURNED.

   
   
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Corporate One West • 1195 Washington Pike • Bridgeville, PA 15017 • customerservice@qorpak.com
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