Dealer Application

BILLING NAME AND ADDRESS

ADDRESS

CITY

PROVINCE

POSTAL CODE

TELEPHONE #

IN BUSINESS SINCE

COMPANY TYPE

WEBSITE

PRODUCTS INTERESTED IN

FIRST CONTACT

TELEPHONE + EXT

PURCHASING CONTACT

TELEPHONE + EXT

ACCOUNTS PAYABLE

TELEPHONE + EXT

DIRECT DEPOSIT

PAYMENT METHOD

CHECK

PAYMENT METHOD

ACCES D

PAYMENT METHOD

CREDIT CARD

PAYMENT METHOD

SHIPPIND NAME AND ADDRESS (leave blank if the same)

SHIPPING ADDRESS (leave blank if the same)

SHIPPING CITY

SHIPPING PROVINCE

SHIPPING POSTAL CODE

SHIPPING TELEPHONE #

MESSAGE

APPLICANT NAME

FUNCTION

Authorization

The applicant acknowledges that he has the authority to open an account on behalf of the company.

136 1st Avenue
Stoneham-et-Tewkesbury,
QC, G3C 2N1