Credit Application

CUSTOMER INFO

Full Company Name *

DBA Name

Street Address (Actual address) *

City *

Postal / ZIP *

State / Province *

Remit to address

City

Postal / ZIP

State / Province

Phone

Fax

Shipping Contact *

Shipping Email *

Shipping Phone *

AP Contact *

AP Email *

AP Phone *

Website Address

Accept e-invoices/pod/statements?

Yes

Yes - Preferred email address(s)

Currency to be billed in

CDN

USD

Federal Id

Business #

Caneda Sales Rep (if applicable)

BANK INFO

Years in Business (2yr Min) *

Partners/Owners *

Credit Amount Applying For *

Name of Banking Institution *

Bank Address *

City *

Postal / ZIP *

State / Province *

Account Number CDN

Account Number USD

Contact Name *

TRADE REFERENCES

Name *

Phone *

Fax *

Name *

Phone *

Fax *

Name

Phone

Fax

Payment terms are net 30 days. Please notify us of any discrepancies immediately. A 3% administration fee will be added to all Credit Card Payments.

* required field