| Registered Business Name | |
| Business Address | |
| Principle line of Business | |
| Date Business Started | |
| Business Telephone (with area code) | |
| Business Fax (with area code) | |
| E-mail Address | |
| Credit Applied for (amount) | |
| PST # | |
| GST # | |
| Federal ID# | |
| Name of owner/proprietor (First) | |
| Position Held | |
| Address | |
| Telephone (with area code) | |
| Fax (with area code) | |
| Social Insurance Number | |
| Name of owner/proprietor (Second) | |
| Position Held | |
| Address | |
| Telephone (with area code) | |
| Fax (with area code) | |
| Social Insurance Number | |
| Trade References ( Please detail below the names of three trade references) | |
| Name | |
| Address | |
| Telephone (with area code) | |
| Fax (with area code) |
|
| Name | |
| Address | |
| Telephone (with area code) | |
| Fax (with area code) | |
| Name | |
| Address | |
| Telephone (with area code) | |
| Fax (with area code) | |
| Bank details | |
| Name of Bank | |
| Account # | |
| Name of Contact Person | |
| Telephone (with area code) | |
| Fax (with area code) | |
| Address | |
| Details of Credit Card | |
| Type of Credit Card | Visa MasterCard |
| Card # | |
| Valid Until | |
| Terms of Payment | |
| All
accounts are due on a fifteen day basis. Overdue accounts will be subject
to a service charge of 1.5% per month. (18% per annum).
I hereby certify the above information to be correct and authorize Country Line Inc. to obtain such credit information as necessary in connection with the establishment and maintenance of a credit account or for any other direct business requirement. This consent is given pursuant to section 12 of the credit reporting Act, R.S.R.C. 1979, Chapter 78. Financial Statement attached. |
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Customer Signature |
Position of signee |
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Date
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