credit application. "*" indicates required fields company informationCompany/Business Name* Operating or Trade Name* Years in Business*Physical Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Is your mailing address the same as your physical address?* Yes No Mailing Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Phone*FaxProvincial Tax NumberProvide your Provincial Tax Number if you are tax exempt. Accounts Payable Contact Name* Phone*Email* Credit Limit Requested*Number of Operating Locations*P.O. Number Required*Does your account department require the use of a P.O. number when making purchase from suppliers? Yes No Company Officers/Owners*Use the +/- at the end of each line to add or remove company officers/owners.NameAddressTitleOwnership % Add RemoveThe customer: A. Authorizes Leech Grup to investigate the customer's credit history and ability to pay. The customer consents to all such investigations and inquiries as may be made by Leech Group to obtain credit information. B. Acknowledges the terms of purchase are as follows: INITIAL ORDER: minimum 50% deposit (amount subject to discretion of Leech Group Ltd.) with order and balance due on delivery. SUBSEQUENT ORDERS: Net 30 days. Interest will be charged on overdue amount at the rate of 2% per month, 24% per annum. C. Acknowledges that the credit information provided on the credit application form and all other credit information given by the customer to Leech Group in the course of the customer's application for credit is complete and accurate in all material respects and that such information is being relied upon for the purpose of granting credit.Signed on:* YYYY dash MM dash DD Signature Reset signature Signature locked. Reset to sign again Title:*Provide your job title or position within your company. references (3 required)I/we do business on an open account with the following firms:Reference #1 - Name* Phone*Email* Fax*Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Reference #2 - Name* Phone*Email* Fax*Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Reference #3 - Name* Phone*Email* Fax*Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code PhoneThis field is for validation purposes and should be left unchanged.
