New Customer Form (Page 2 of 2) in pdf

Ottawa

Vancouver

Montreal

Halifax

Walnut, CA. U.S.A.

Calgary

Toronto

Tel: 613-746-8227

Tel: 888-908-7368

Tel: 604-303-0206

Tel: 514-333-6538

Tel: 902-468-0030

Tel: 403-450-3434

Tel: 905-470-0082

Fax:613-746-8679

Fax:888-316-7383

Fax:604-303-0207

Fax:514-333-6549

Fax:902-468-0040

Fax:403-450-3435

Fax:905-470-3183

NEW CUSTOMER FORM

BANK REFERENCE

Name of Bank:___________________________________ Branch: ______________________ Account No.: _______________________

Address: _______________________________________________ City / Prov: __________________________ Postal Code: __________

Contact: ____________________________Tel: __________________________

Fax: _______________________________

TRADE REFERENCES

Name: ___________________________________________________ Tel: ______________________ Fax: ______________________

Contact: ____________________________________ Credit Limit: _____________________ Payment Terms: ____________________

Name: ___________________________________________________ Tel: ______________________ Fax: ______________________

Contact: ____________________________________ Credit Limit: _____________________ Payment Terms: ____________________

Name: ___________________________________________________ Tel: ______________________ Fax: ______________________

Contact: ____________________________________ Credit Limit: _____________________ Payment Terms: ____________________

I/We certify that the information contained in this form is true and correct. Furthermore, I/We understand that all products are shipped without insurance, unless otherwise

specified, and shipping losses and damages are my/our responsibility.

I/We consent to the obtaining of bank/credit and/or personal information as may be required at any time in connection with this New Customer Form and to the disclosure of any

bank/credit information concerning me/us and/or my/our company to any credit reporting agency or to any person with the undersigned has or proposes to have financial relations.

I/We further agree to indemnify ELCO Systems from all claims, which may arise because ELCO Systems disclosed information about myself/us and/or my/our company.

Name (Print): ____________________________________________

Title: ____________________________________________

Authorized Signature: ____________________________________

Date: _____________________________

Name (Print): ____________________________________________

Title: ____________________________________________

Authorized Signature: ____________________________________

Date: _____________________________

Please completely fill in the application to allow us to better serve and support you!

Please fax back this form with a Void Company Cheque, Vendor Permit.

New Customer Form

(PK-02-12)