Trade Name (in full):
Physical Address of Location:
Billing Address (if different):
Is Applicant An Incorporated Company?
If "Yes", Corporate Name:
or Incorporation Number:
Province of Incorporation:
Date of Incorporation:
Name And Position of Principals (1):
Accounts Payable Contact:
Phone:
*Email:
Nature of Business:
GST Number:
Year Commenced Business:
Bank Name:
Bank Address:
Account Number:
I/We apply to you for credit for the supply of services and materials. I/We jointly and severally indemnify you, and see you paid for your account with respect to any order or hereafter made by any of us on our behalf. I/We further agree to pay your account within your terms of net 30 days. In the event the account is delinquent and satisfactory arrangements have not been made for payment, I/We further agree to pay all Solicitor/Client fees and Disbursements incurred by you for taking any collection action. I/We consent to your obtaining and reporting our credit information.
Print name of authorized person completing form
Date:
Total Amount of Credit Required:
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