Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. New Customer Account Information NEW CUSTOMER ACCOUNT INFORMATION Customer Number Account Rep NEW CUSTOMER INFORMATION (All New Customers Must Fill Out) To begin processing your order to meet your delivery schedule, the following information is required. Your expedited handling of this application will enable your order to be processed in a timely manner. Account Application Company Name Owner Physical Business Address Shipping Address Phone Email Invoicing Address Accounts Payable Contact Email For Invoices PO Required For Payment? Yes No Type Of Business Years In Business Years At Present Location Type Of Organization Public Partnership Corporation Individual Credit Application If you wish to apply for Net 30 term please sign and complete this application. The default credit limit will be $1,000 unless additional credit is requested. Credit Terms COD Net 30 Invoice With Goods Visa On File Credit Limit Requested Account Manager Bank Name Account Number Address Account Type Select Chequing Savings Business Fax Trade References (3 Minimum, 4 Preferred) Company Name Address Phone Fax Or Email If you are PST and/or GST exempt, an exemption form must accompany this application. PST Exempt Yes No GST Exempt Yes No I certify that the information on this application is correct. I understand the terms are net 30 from date of invoice. People Allowed To Place On Account Additional Notes Chemical Purchase Requirements Please note: If below is not provided you will not be able to purchase chemicals. We do not sell chemicals without a commercial address and proof below. Business Licence Upload Proof Of Insurance Upload Digital Signature Draw Signature Clear Signature Upload Signature Image Accepted formats: PNG, JPG, JPEG Signature Name Title Date Submit Credit Application Submit
