18 May 2012

Third-Party Qualification.

Third-Party Qualification Form

This form is for qualification of any third party wishing to do business with Laurell Technologies Corporation, sales.

If your requirement is urgent, please fill in the form, submit, and then call us.

* Indicates a required field.

Privacy Policy

Simply stated, we do not share your sensitive personal information with anyone else.

Rest assured that your e-mail address, telephone number, other private information stays confidential. The only time we will contact you is to follow up on an order or a request for a quotation or support.

Primary Information

Inside USA?

Yes No

Is this a single one-time bid request?

Yes No

Insert specific bid request, if any, here:

Contact Information

First Name*

Last Name*

Organization*

Address 1*

Address 2

Address 3

(internal mail stop/code)

City*

State (USA only)*

ZIP / Postal Code*

Country*

Phone #*

Fax #

E-mail*

(corporate/university domain only)

WARNING:

You may not receive a proposal if you are using a personal e-mail address. Please enter your company or institution-specific e-mail address.

Website

Sales Information

Territory Covered*

Average Sale*

(in USD)

Average Yearly Sales*

(in USD)

Years in Business*

Can you stock spare parts?

Yes No

Can you buy and resell?

Yes No

Can you install equipment?

Yes No

Can provide support?

Yes No

State briefly your specific intentions,
any references, and all qualifications:

Insert line card (list of products and services) here:

How did you hear about Laurell?

Web Search
Through a professional trade association
I am a current or previous Laurell customer
I was referred by another satisfied customer
Other

How would you like us to respond to you?

By e-Mail By FTP Hard copy via postal mail

(You may choose more than one.)