Credit Application

Business Name of Applicant/Full Legal Name

President / Owner

Address

City/Province

Postal Code

Phone

Fax

Email

Years in Business

Credit References

Reference #1

Account with

Address

City/Province

Postal Code

Phone

Contact

Reference #2

Account with

Address

City/Province

Postal Code

Phone

Contact

Reference #3

Account with

Address

City/Province

Postal Code

Phone

Contact

Bank Reference

Bank

Address

City/Province

Postal Code

Phone

Contact

Terms

Credit Limit Requested

Verification

I/WE, THE UNDERSIGNED, CERTIFY THAT THE ABOVE INFORMATION IS CORRECT AND I/WE ARE HEREBY DULY AUTHORIZED TO SIGN THIS APPLICATION. I/WE AGREE THAT THE USUAL CREDIT INQUIRIES MAY BE MADE AT ANY TIME, REGARDING THE CREDIT HEREBY APPLIED FOR, AND CONSENT TO THE DISCOLSURE OF ANY INFORMATION CONCERNING THE UNDERSIGNED TO ANY REPORTING AGENCY, PERSON OR FIRM WITH WHOM THE UNDERSIGNED MAY OR MAY HAVE FINANCIAL RELATIONS. I/WE AGREE THAT SHOULD, AT ANY TIME, THE ACCOUNT BECOME OVERDUE, AGREE TO JOINTLY AND SEVERALLY INDEMNIFY YOU AND SEE YOU PAID FOR ALL DEBTS INCURRED AS A RESULT OF THIS APPLICATION. THE CREDITOR RESERVES THE RIGHT, AT IT’S SOLE DISCRETION BASED ON EVALUATION OF CUSTOMER WORTHINESS, TO AMEND/WITHDRAW CREDIT FROM TIME TO TIME.

Name

Date