Customer Information Form

To begin, Please let us know which staff member asked you to complete this form ?*

Company Name (operating as)*

Legal Company Name:

Main Contact*

First NameLast Name

Bill To: Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Bill To: Contact Name

First NameLast Name

Phone Number*

E-mail

Ship To: Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Country

Ship To: Contact Name

First NameLast Name

Phone Number*

E-mail

Type of Business

CorporationPartnershipProprietorshipSubsidiary

Years in Operation

Are Purchase Orders Required ?*

YESNO

Preferred payment method

EFT / Direct DepositCredit CardCheque

President / CEO

First NameLast Name

Email

Treasurer/Controller:

First NameLast Name

Email

Authorized Buyers:

	Full Name	Email Address	Contact Number
1
2
3

Accounts Payable Contact Person | Invoice emailed to:

First NameLast Name

Phone Number*

E-mail

Confirmation Email

Terms Requested

CODNET 15NET 30NET 45

Credit Limit Requested

Statement Emailed to:

PST Exempt Number

GST Exempt Number

Treaty Band Number

Bank

Name

First NameLast Name

Phone Number

Please enter a valid phone number.

Bank Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Company Name

Legal Name

Contact Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.

Company Name

Legal Name

Contact Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.

Company Name

Legal Name

Contact Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.

Email

example@example.com

Phone Number

Please enter a valid phone number.

(1) BUYER CERTIFIES TO THE CORRECTNESS OF THE INFORMATION IN THIS APPLICATION. (2) BUYER RECOGNIZES SELLER’S TERMS AS NET 30 DAYS, AND ACKNOWLEDGES AND AUTHORIZES A SERVICE CHARGE OF 2.5% PER MONTH (30% ANNUAL) ON ANY PAST DUE AMOUNTS. SELLER SHALL HAVE THE RIGHT (A) TO DECLARE THE ENTIRE AMOUNT DUE AND PAYBLE IF DEFAULT OCCURS IN MAKING ANY PAYMENT WHEN DUE, AND IN THAT EVENT CUSTOMER AGREES TO PAY REASONABLE ATTORNEY AND/OR COLLECTION AGENCY FEES (B) TO CHANGE THE TERMS OF THE ACCOUNT FROM TIME TO TIME (CONSISTENT WITH APPLICABLE LAW) TO BE EFFECTIVE NOT LESS THAN THIRTY (30) DAYS AFTER GIVING WRITTEN NOTICE. (C) TO LIMIT THE AMOUNT OF CREDIT EXTENDED UNDER THIS ACCOUNT OR TERMINATE THE ACCOUNT, UPON GIVING WRITTEN NOTICE THEREOF, BUT SELLER MAY AVAIL ITSELF OF THE TERMS OF THIS AGREEMENT UNTIL FULL PAYMENT OF THE ENTIRE BALANCE WITH FINANCE CHARGES TO DAY OF PAYMENT HAS BEEN RECEIVED. (3) IN SUBMITTING THIS APPLICATION FOR CREDIT, I/WE AUTHORIZE YOU TO INVESTIGATE MY/OUR CREDIT RECORD.
I CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND AGREE TO THE ABOVE STATEMENT.

Name

First NameLast Name

Title

Date

Signature

How did you hear about us?*

Please Specify*

Which Socials do you use ?

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New Customer CREDIT REQUEST Form

Customer information

Business Information

Tax Information

Bank information

Trade References

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Marketing