Credit Application

Please complete the form below. Fields marked with an asterisk (*) are required.

Company

Company Name *

Phone *

Order Email *

Billing Email *

Years in Business *

Company Type *

Requested Credit Limit *

Accounts Payable Contact *

Billing Address *

City (Billing) *

Province/State (Billing) *

Postal/ZIP (Billing) *

Same as billing

Shipping Address *

City (Shipping) *

Province/State (Shipping) *

Postal/ZIP (Shipping) *

Bank/Institution *

Institution Address *

Institution Phone *

Reference 1 (required)

Name *

Email *

Phone *

Reference 2 (required)

Name *

Email *

Phone *

Reference 3 (optional)

Name

Phone

Were you referred by a sales representative? *

Yes

Our payment terms are Net 30 days. Past-due accounts are subject to 2% monthly interest (24%/year).

I certify the information provided is accurate and authorize a credit check. *

Name of person completing the application *

Date *