Qualitex
 

REQUEST TO DISTRIBUTE

To apply to become a Qualitex distributor, please complete the following form and a company representative will contact you shortly.

Distributor Request Form
First Name
Last Name
Title
Company
Email
Address
City
State / Province
Zip / Postal Code
Country
Phone
Fax
Sales Territory
Are You Currently Selling Our Products?
Five (5) Trade References
Bank Information
Additional Information (Optional)


Qualitex Company 4248 N. Elston Avenue Chicago Illinois 60618 • 773.463.6777 • fax 773.463.5731