Contact Information
Name / Trade Name
Address
City
Postal Code
Phone
Fax
Contact
Name of Principles
Title
Name of Principles
Title
Social Security Number
Numbers of Years in Business
Truck #'s
Type of Firm: Partnership Proprietorship Corporation
Anticipated Monthly Purchases:	$
P.S.T. Exempt #
G.S.T. Exempt #
BANKING INFORMATION
Bank Name
Contact
Address
Account Number
Phone Number / Area Code
TRADE REFERANCES
1 Company Name Contact / Phone Number Address 2 Company Name Contact / Phone Number Address 3 Company Name Contact / Phone Number Address
If credit is extended to you, who is authorized to charge on your behalf ?
AUTHORIZATION AND DATE
CONSENT: I (we) hereby authorize to obtain credit or other information as may be deemed necessary in connection with the establishment and maintenance of a credit account or for any other direct business required. I (we) ( Company Name ) understand that accounts in arrears are subject to a service charge at a rate of 1 1/2 % per month on outstanding balances in excess of 30 days. Accounts not paid within 30 days are considered past due and may cause interruption in credit extended. I further agree to pay collection and / or legal fees incurred by . in collection of any past due amounts
Application Date Signed By: Print your name here: Your E-Mail Address
Enter Today's Date: (2010/01/31) -- We need to ask you this, to prevent spam-bots from flooding our Dealers in-boxes. Please use the exact yyyy-mm-dd format.

The information you are submitting in not encrypted.