Canawipe

~ACCOUNT APPLICATION FORM~

New applicant
Update existing account

~GENERAL INFORMATION ~

Company:

First name:

Last name:

Phone:

Extension

Alt Phone:

Extension:

Fax:

Address:

Unit #:

Province/State:

Country:

Postal Code:

Email:

Website:

Amount of Credit Requested:

$1,000 - $3,000 (?)
$3,000 - $5,000
$5,000+

AP Contact:

Phone:

Extension:

Email:

Business License:

Sole Prorietor
Partnership
Corporation
Limited

Tax Exempt #:

# of years in business:

Type of business:

Retail
Wholesale
Government
Distribution
Online Retailer
Other:

If selected "other" please specify:

Markets Served:

Buying Group:

Buying Contact:

Buying Phone:

~OFFICERS &/OR PRINCIPALS INFORMATION~

Name:

Tittle:

Address:

I accept a personal Guarantee

Name:

Tittle:

Address:

I accept a personal Guarantee

~BANKING INFORMATION~

Contact Name:

Phone #:

Branch - Account #:

Alt Contact:

Name:

Alt Phone:

Alt Branch:

Account #:

~Trade References~

~Reference #1~

Name:

Contact:

Phone:

Fax:

~Reference #2~

Name:

Contact:

Phone:

Fax:

~Reference #3~

Name:

Contact:

Phone:

Fax:

~Authorization~

The Applicat Authozies their bank or any other entity or source of information to release to Canawipe Distribution Ltd. Its employees, credit and financial information concerning the applicant at any time.

I Herby declair by checking this box account as my signature and give full legal rights to the information above.

Name/Signature:

Date:

Email:

Message:

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