Name of Applicant:
Date:
Street/Mailing Address:
City:
Prov.:
Postal Code:
Telephone Number:
Fax Number:
Cellular Number:
Name of Owners/Operator (Name/Title/Phone Number)
Type of Business:
Year Established:
Nature of Business: CorporationPartnershipProprietorship
Provincial Sales Tax Number:
Goods & Services Tax Number:
Estimated Monthly Credit Required $
Bank
Phone
Address
Business References:
Reference 1
Name:
Phone:
Address:
Fax:
Reference 2
Reference 3
Should a charge account be approved, I/We hereby promise to pay the outstanding balance in accordance with the terms of sale. I/We agree to pay an interest charge of 2 per cent per month on any overdue balance.
Signature:
Title:
Email:
Accept terms
I/We hereby authorize Wurtz Bros. Ltd. or it’s agents to conduct such investigations as are deemed necessary to my/our application for credit. Wurtz Bros. Ltd. reserves the right to accept or cancel this I/We hereby agree to pay your account (if opened) according to your terms.
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