Gastown Supply Co Dealer Application

Dealer Application
Please note Gastown Supply Co provides distribution for Canada only.
Legal Business Name*
Contact Name*
E-mail*
Phone Number*

Area CodePhone Number
GST #*
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Is billing address and shipping address the same?

Yes
Shipping Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Terms Requested*

PrepayCredit Card*NetE-Transfer
Please note first 3 orders are prepay.

*2% merchant fee applies to credit card payments.

All cancelled prebook orders at the time of shipping will incur a 20% restocking fee.
CREDIT CARD AUTHORIZATION
If Dealer defaults, based upon my personal guarantee, Supra is authorized to charge my credit card for all sums due and to become due to Supra by Dealer. This includes all losses, costs, attorney’s fees, or expenses that Supra might suffer by reason of Dealer’s default.
Card Holder Name

First NameLast Name
Card Holder Phone Number

Area CodePhone Number
Card Holder Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
TRADE REFERENCE
**Please Note**

References MUST BE FILLED OUT COMPLETELY for your application to be processed in a timely manor. Please make sure to include head office information. No reps/rep agencies will be accepted.
Trade Reference Name*

First NameLast Name
Trade Reference Phone Number*

Area CodePhone Number
Trade Reference Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Should be Empty:

Dealer Application

CREDIT CARD AUTHORIZATION

TRADE REFERENCE