ACTIVE CHEMICALS CREDIT APPLICATION

CREDIT APPLICATION
To permit us to open a new account please supply the following information. This information is collected in accordance with our Privacy Policy. We would need three credit references to open a credit account.
Company Name :*
Contact Name : *

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PST Exemption #
Currency :*

Canadian DollarsUS Dollars
Quotation # / Salesperson
( Optional )

A/P Contact info
Accounts payable Contact name *

First NameLast Name
Email Invoices to :- *
example@example.com
Phone Number*
Please enter a valid phone number.
File Upload

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Credit References 1
Company *
Reference 1
Email *
example@example.com
Contact Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Credit References 2
Company *
Reference 2
Email *
example@example.com
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Credit References 3
Company *
Reference 3
Email *
example@example.com
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Please verify that you are human*
Should be Empty: