Legal name of business:

Trade name:

Telephone #:

Fax #:

Address:

Province:

Postal Code:

Email Address:

Proprietorship:

Partnership:

Corporation:

If applicant is a subsidiary,

please name parent company:

Principal owner/shareholder:

Home Address:

Telephone #:

Previous employment if in

business less than 2 years:

Other Officers:

Title:

Other Officers:

Title:

Name of contact person

responsible for (applicant):

Title:

Are any of the owner/officers now

or in the past 7 years in

bankruptcy proceedings?:

If so, state details:

Annual Sales $:

Net worth of company $:

Number of employees:

Credit line desired:

Name of bank:

Bank Account #:

Assets Pledged?:

Name of Supplier:

Telephone #:

Fax#:

Name of Supplier:

Telephone #:

Fax #:

Legal form of business:

Name of Supplier:

Telephone #:

Fax #: