Duratek Equipements

Products

ACCOUNT APPLICATION FORM

Invoicing:

Name Invoice *

Address *

City *

Province

Post Code *

Telephone *

Fax *

Email *

Responsible Account

Type Business

Established Since

Tax Exemption Number

Delivery:

Name Deliver

Address Deliver

City Deliver

Province Deliver

Post Code Deliver

Telephone Deliver

Fax Deliver

Email Deliver

Newsletters and catalogs:

Want Catalog
Yes No

Want Newsletter
Yes No

Email Want

Owner

Name Owner

Address Owner

City Owner

Province Owner

Post Code Owner

Telephone Owner

Fax Owner

Email Owner

Is Owner Another Business
Yes No

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

Name (1) :

Address

City

Province

Post Code

Telephone

Fax

Name (2) :

Address

City

Province

Post Code

Telephone

Fax

Legal nature of company:

Legal Nature Type
Self-employed
Partnership
Private limited company

List of associates or shareholders:

Name	Address	Position

Banking information

Bank

Address

City

Province

Post Code

Telephone

Fax

Supplier references

Supplier info

Name	Contact	Telephone
1)
2)
3)
4)

Signature info

Sign

Name

Title

Date

Documents attached to this form:

Has Business Card
Has Form Discount Condition Signed
Has Initial Order 50 Payment
Has Grid Duly Signed

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: