Duratek Equipements

Products

ACCOUNT APPLICATION FORM

Invoicing:

Invoice to (name on account): *

Address: *

City: *

Province:

Postal code: *

Phone: *

Fax: *

Email address: *

Accounts payable accountant:

Company type:

Established since:

Tax exemption #:

Delivery:

Delivered to (name on account):

Address:

City:

Province :

Postal code:

Phone:

Fax:

Email address:

Newsletters and catalogs:

Do you wish to receive our catalog?
Yes No

Do you wish to receive our electronic newsletter?
Yes No

If so, what is your email address?

Owner

Name of owner:

Home address:

City:

Province:

Postal code:

Phone:

Fax:

Email address:

Are you or have you ever been owner of another store?
Yes No

If so, please indicate the names and addresses of other stores:

Name of store (1) :

Address of store:

City:

Province:

Postal code:

Phone:

Fax:

Email address:

Name of store (2) :

Address of store:

City:

Province:

Postal code:

Phone:

Fax:

Email address:

Legal nature of company:

Please choose one of the following options:
Self-employed
Partnership
Private limited company

List of associates or shareholders:

Name	Address	Extension

Banking information

Bank:

Address:

City:

Province:

Postal code:

Phone:

Fax:

Email address:

Supplier references

Please enter the names and phone numbers of four suppliers who can provide us with credit references.

Supplier name	Contact	Phone and fax number
1)
2)
3)
4)

Your signature certifies your financial responsibility, as well as your ability and willingness to pay amounts due on the account in accordance with our terms of sale.

Signature:

Name:

Title:

Date:

Documents attached to this form:

Business card
Forms and terms of sale duly signed
Initial order and 50% of payment of net value
Duly signed evaluation grid

Products

ACCOUNT APPLICATION FORM

Company information

Invoicing:

Delivery:

Newsletters and catalogs:

Owner

If so, please indicate the names and addresses of other stores:

Legal nature of company:

List of associates or shareholders:

Banking information

Supplier references

Documents attached to this form: