CREDIT APPLICATION Company Name * Shipping/Receiving Street Address * City * State * Select a State/Province Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware D.C. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick New Foundland Nova Scotia Northwest Territory Ontario Price Edward Island Quebec Saskatchewan Yukon Zip * Phone * Fax GST Billing Address * City * State * Select a State/Province Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware D.C. Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Alberta British Columbia Manitoba New Brunswick New Foundland Nova Scotia Northwest Territory Ontario Price Edward Island Quebec Saskatchewan Yukon Zip * Date of Incorporation / Partnership* Duns 1.Names of Principals Officers * Title * 2.Names of Principals Officers Title Billing Currency CDN US A/P Contact Name Estimated Monthly Credit Requirement Special Billing Instructions Bank * Address * Branch * Phone * Customs Broker Phone Credit Reference Number Of Credit Reference 1 2 3 To the best of my knowledge the above statements are true. My signature below A) indicates my permission to obtain credit information from the sources referenced and B) attests financial responsibility and willingness to pay invoices in accordance with terms. Credit Terms are 30 Days Signature * DATE * Position * Sales Executive Code * (Office use only) Collection procedures are governed by items 435 and/or 440 of the rules of VCTS 100 Approval DATE Limit Enter the contents of image *
