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:PartnershipProprietorshipCorporation
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 maybe deemed necessary in connection with the establishment and maintenanceof a credit account or for any other direct business required. I (we)( Company Name ) understand that accounts in arrears are subjectto a service charge at a rate of 1 1/2 % per month on outstandingbalances in excess of 30 days. Accounts not paid within 30 daysare considered past due and may cause interruption in credit extended.I further agree to pay collection and / or legal fees incurredby . in collection of any past dueamounts
Application Date Signed By:   Print your name here: Your E-Mail Address

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