Company Information:

Account No: 

Company Name: 

Address 1: 

Address 2: 

City: 

Province/State:  - Please select one. -

Country:  - Please select one. -

Postal Code/Zip: 

Other Country: 

Phone: 

Extension: 

Fax: 

Business Information:

Legal Name: 

Legal Form:

 Corporation

 Sole Proprietor

 Partnership

Start Date:  - Please select one. -

President/Owner/CEO:

# of Employees:  - Please select one. -

Annual Sales:  - Please select one. -

PST # or State Tax #:

GST # or Fed.ID#/SSN#:

Shipping Information:

Company Name: 

First Name: 

Last Name: 

Salutation:  Mr.  Mrs.  Ms.  Miss

Address 1: 

Address 2: 

City: 

Province/State:  - Please select one. -

Other: 

Postal Code/Zip: 

Country:  - Please select one. -

Other: 

Phone: 

Extension: 

Fax: 

E-Mail: 

Bank Information:

Bank Name: 

Branch #: 

Bank Account#: 

Acct. Manager: 

Bank Phone: 

Bank Fax: 

Bank E-mail: 

3 trade references:

1.

Company Name: 

Contact: 

Phone: 

Extension: 

Fax: 

E-mail: 

Monthly
Credit Limit: 

2.

Company Name: 

Contact: 

Phone: 

Extension: 

Fax: 

E-mail: 

Monthly
Credit Limit: 

3.

Company Name: 

Contact: 

Phone: 

Extension: 

Fax: 

E-mail: 

Monthly
Credit Limit: