CREDIT APPLICATION
669 Derwent Way, Delta, BC V3M 5P7
PHONE: 604 521 9315 FAX: 604 521 9307
FULL LEGAL BUSINESS NAME:
COMPLETE MAILING ADDRESS:
COMPLETE PHYSICAL ADDRESS:
HEAD OFFICE, MAILING ADDRESS:
HEAD OFFICE, PHYSICAL ADDRESS:
PHONE:
FAX:
ALTERNATE PHONE:
ALTERNATE FAX:
ACCOUNTS PAYABLE CONTACT:
PRINCIPLE BUSINESS CONTACT:
CREDIT DESIRED:
YEARS IN BUSINESS:
DO YOU REQUIRE PURCHASE ORDER NUMBERS?
WHAT LINE OF BUSINESS ARE YOU IN?
□ YES
□ NO
NAME OF OWNERS
NAME OF OWNERS
1.
2.
NAME OF OWNERS
NAME OF OWNERS
3.
4.
PRINCIPALS OF COMPANY (NAME & TITLE)
PRINCIPALS OF COMPANY (NAME & TITLE)
1.
2.
PRINCIPALS OF COMPANY (NAME & TITLE)
PRINCIPALS OF COMPANY (NAME & TITLE)
3.
4.
ARE ANY OF THE OWNERS/OFFICERS NOW OR IN THE PAST 5 YEARS IN BANKRUPTCY PROCEEDINGS?
(IF YES, PLEASE PROVIDE EXPLANATION)
TRADE REFERENCES
NAME:
PHONE:
FAX:
CONTACT:
NAME:
PHONE:
FAX:
CONTACT:
NAME:
PHONE:
FAX:
CONTACT:
BANK REFERENCES
NAME:
PHONE:
CONTACT:
ADDRESS:
FAX:
ACCOUNT#:
By signing below, you agree to all terms and conditions as specified on page 1 of the “Application of Credit”.
DATE:
AUTHORIZING APPLICANT NAME
AUTHORIZING APPLICANT SIGNATURE:
(PLEASE PRINT):
PLEASE FAX COMPLETED FORM TO: 604 521 9307