*Email Address:

Please enter your email address.

*Legal Business Name:

*Street Address:

*City:

*Province:

*Postal Code:

*Telephone:

Fax:

*Your Accounts Receivable Contact:

*Your busines is:

Proprietorship

Partnership

Corporation

Other

Check one.

*Add names, titles & phone numbers of partners, shareholders, or officers and directors:

Do you have any special invoicing requirements?

*Are purchase order numbers manditory when your company orders product?

Yes

No

Check one.

*Are you tax exempt?

Yes

No

Check one.

If you are tax exempt, what is your tax certificate number?

Please provide your tax number.

Which of the following banks do you deal with:

Royal Bank

Bank of Montreal

Toronto Dominion Bank

Bank of Nova Scotia

CIBC

Other

Check applicable boxes.

*Account Number:

Type of Account:

Checking

Savings

Loan

Line of Credit

Check appropriate accounts.

*Branch:

*Manager or Branch Contact:

Company's Year End:

*Based on 2 months purchases, identify amount of credit requested:

*Has the company, or any of its officers, partners, or the applicant ever been bankrupt before?

Yes

No

Other

Check one.

If you answered yes to the above question, identify when:

Please provide specific date.

*Add your name, title & date:

(* indicates a required field.)