Online Credit Application

1. CONTACT INFORMATION

Customer's Legal Name::

Customer Trade Name::

Address::

P.O.Box::

City::

Province/State::

Postal/ZipCode::

Phone::

( format : 999-999-9999)

Fax::

Email::

2. COMPANY DETAILS

Line of Business::

Type of Business::

Number of Employees::

How Long Have You Been in Business?::

3. COMPANY MANAGEMENT- officers, directors, partners

4. PAYABLES INFORMATION

Your Accounts Payable Contact::

Purchase Orders Required?::

Special Invoicing Requirements::

5. SUPPLIER REFERENCES

6. BANKING & FINANCIALS

Bank Name::

Branch Address::

Account Number::

Telephone::

( format : 999-999-9999)

Bank Contact Name::

Financial Statements Available in Confidence?::

Amount of Credit requested?::

Has the applicant business or any of it's officers, partners, or directors ever declared bankruptcy?

Yes, Date Declared:: No