StockCheck Account Fax Application

Stockcheck Account Application

Fill out this application, print it, sign the bottom, and fax it to (972) 943-1319.

Company Name:
Marketing/Sales Contact:
Marketing/Sales Contact Phone:
Marketing/Sales Email:
Inventory Contact:
Inventory Contact Phone:
Inventory Contact Email:
Company Address:
City:
State/Province:
Zip/Postal Code:
Country:

Contact Information (to be displayed online):
Phone 1:
Phone 2:
Fax:
Sales Email:
RFQ Email:
URL:
eCommerce/ShoppingCart URL:
*Check this box if you do not* wish to be displayed on www.chipsource.com:**
Disclaimer: Hearst Business Communications Inc. endeavors to accurately reflect your inventory on our system with data supplied by your company. The undersigned agrees to hold Hearst Business Communications Inc. harmless from any liability resulting from inaccuracies, omissions, use or lack of use of the data that may appear on our system. In addition, Hearst Business Communications Inc. reserves the right to discontinue listings, at its sole discretion.

Signature:	____________________________________________
Print Name:	____________________________________________
Date:	_____________________

FAX COMPLETED FORM TO Stockcheck : (972) 943-1319