| Company Name: |
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| Contact Person: |
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| Address: |
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| Fax: |
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| Telephone: |
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| Fax Number: |
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| E-mail: |
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| Web Site: |
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| Please Complete Appropriate Spaces: |
| Corporation: |
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| President: |
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| Partnership: |
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| Vice-President: |
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| Proprietorship: |
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| Secretary: |
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| Municipality: |
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| Treasurer: |
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| Owner/Operator: |
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| Owner/Operator: |
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| Date Business Started: |
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| State of Incorporation: |
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| Year: |
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| Taxable: |
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| Non-Taxable: |
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| Permit Number: |
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| NOTE: A COPY OF YOUR PERMIT MUST
BE ENCLOSED WITH THIS APPLICATION. |
| Name of Person(s) Authorized To Order Material: |
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| Estimated Monthly Volume: |
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| Bank Name: |
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| Address: |
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| Telephone: |
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| Account Number:(ACCOUNT # MUST BE
PROVIDED) |
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| Officers Name: |
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| Business or Trade References (Name,
Address, Phone Number and Fax Number) |
| 1. |
| 2. |
| 3. |
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I (We) understand that the
information furnished you hereof, is for the purpose of
obtaining credit from your firm. That I am (we are) authorized
in my (our) capacity,
to bind my (our) firm accordingly. That all accounts of monies
due you shall be due
and payable at your place of business. That all past due
accounts, notes or judgments shall automatically draw interest
at the rate of eighteen percent (18%) per annum.
In the event of default, I (we) agree to pay all costs of
collection including court costs and reasonable attorneys fees.
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| Signature / Date |
Signature / Date |
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| The undersigned certifies that all
the merchandise purchased will be purchased for resale or
further processing and therefore, exempt from the provisions
of the Sales Tax Act. This certificate shall be considered a
part of each order which the undersigned shall give unless
such order otherwise specifies. This certificate is to
continue in force until revoked in writing. |
| Exemption Certificate Number (Enclose
copy): |
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| Purchaser Name: |
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| Address: |
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| By: |
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| Date: |
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