Legal Name of Business:
Company is a: Proprietorship, Partnership, Corporation
I.R.S.#:
(Required for customs clearance)
Length of Time in Business: # of Employees:
Officers / Owners:
Name: Title:
Name: Title:
Bank - If more than one please list
Name & Address:
Acct. #:
Contact: Phone:
Name & Address:
Acct. #:
Contact: Phone:
Trade References:
Name & Address:
Phone: Fax:
Name & Address:
Phone: Fax:
Name & Address:
Phone: Fax:
Authorized Purchasing Agent:
The undersigned as an inducement to grant credit warrants that the
information submitted is true and correct. You are authorized to investigate the credit
references listed above at any time in connection with the credit applied for or
any renewal or extension, and to the disclosure of any information concerning the
undersigned to any credit reporting agency or any person with whom the
undersigned has or or proposes to have financial relations. The applicant further
agrees to pay any collection costs incurred to collect unpaid balance, including
interest on the unpaid balance as allowed by state law and any reasonable
attorney's fees incurred.
Date: Signed: _____________________________________
(Please fill out, print, sign and
fax to (905) 561-2362)
