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Registered / Legal Name of Businss
Company Structure:
Corporation
Partnership
Sole Proprietorship
Company Mailing Address
Street Address
Street Address Line 2
City
State
Postal Code
Province
Please Select
AB
BC
MB
NB
NL
NT
NS
NU
ON
PE
QC
SK
YT
Other
The property is:
owned
leased
rented
Primary Phone Number
Format: (000) 000-0000.
Primary Fax Number
Format: (000) 000-0000.
Primary E-mail
Copies of invoices will be sent to this address
Owners & Principal Officers
Owner 1
First Name
Last Name
Owner 1 Direct Phone Number
Format: (000) 000-0000.
extension
This is a:
cell phone number
home phone number
company phone number
Owner 1 E-mail
Additional Owners (if applicable)
Owner 2
First Name
Last Name
Owner 2 Direct Phone Number
Format: (000) 000-0000.
extension
This is a:
cell phone number
home phone number
company phone number
Owner 2 E-mail
Owner 3
First Name
Last Name
Owner 3 Direct Phone Number
Format: (000) 000-0000.
extension
This is a:
cell phone number
home phone number
company phone number
Owner 3 E-mail
Purchasing Contact
Purchasing Contact
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Email
Additional Authorized Purchasers (if applicable)
If more than 5 purchasers, please submit your list of names and contact info to ar@connon.ca
Rows
First & Last Name
Phone #
E-mail
1
2
3
4
5
Credit References
Credit references should be unsecured trade credit (ie. credit which is not collateralized by an asset)
Rows
Company Name
Contact Name
A/R Phone #
A/R E-mail or Fax #
Reference 1
Reference 2
Reference 3
Approximate credit limit required
ex) $5,000
Accounts Payable Contact
A/P Name
First Name
Last Name
A/P Phone Number
Format: (000) 000-0000.
Extension Number
A/P Fax Number
Format: (000) 000-0000.
A/P E-mail
Invoices and statements will be sent to this address
Signing Authority Name
First Name
Last Name
Title
Signing Authority Declaration
I/We hereby certify that the above information is true and complete, and authorize our bank and references to release any information necessary to assist in establishing a line of credit and agree to pay our account according to terms, and to pay all collection fees, reasonable attorney fees, court costs, and other expenses incurred by Connon Nurseries Inc. to obtain recovery of amounts due in the event of nonpayment.
Signature
Date
-
Year
-
Month
Day
Date Picker Icon
Applicant E-mail
A copy of this form will be sent to above e-mail upon submission
Submit
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