Pet Food Source: Register

Confidential Credit Application and Agreement Of
Pet Food Source
(hereinafter referred to as the Credit Grantor)

This Credit Application/Agreement to the Credit Grantor must be fully completed signed and returned before your credit request can be considered. This agreement will govern all sales to you by the Credit Grantor be it product or service on the terms and conditions set forth by the Credit Grantor or which may be established as the policy from time to time by the Credit Grantor. Sales representatives or agents of the Credit Grantor are not authorized to amend or change the terms of sale or other terms and conditions of this agreement.

Usernames and passwords are case-sensitive.

Username: * the name that you use to login
Real Name: *
Password: *	(Min. 8 chars.)
Re-type Password: *
Email Address: *
Re-type Email Address: *
Hide email address?:	Yes No
General Details
Legal name: *
Entity Type: *
GST Number
PST Number
Bill to address: *
Phone: *
Cellular:
Fax:
Ship to address:
Years at present address: *
present address? *
Years in business:
If renting, landlord�s name and phone number
Has there been any Bankruptcy, Receivership or Lit *
Ownership Details
Principal owner/partner Name: *
Owner Home Address: *
Principal owner Home Phone Number: *
Estimated Amount of credit requested:
Name and title(s) of people needed on cheque: *
Name and person in charge of account payables: *
Owner/Partner # 2:
Owner/Partner # 2 Home Address:
Owner/Partner # 2 Home Phone Number:
Trade supplier references:
First Company Name: *
First Company Address: *
First Company Phone Number: *
First Company Fax Number:
First Company E-Mail Address:
Second Company Name
Second Company Address
Second Company Phone:
Second Company Fax:
Second Company Email:
Financial Institution(s) info if payment by cheque
First Institution Name:
Institution Contact Person:
Institution Address:
Institution Phone Number
Second Institution Name:
Second Institution Contact:
Second Institution Address:
Second Institution Phone Number:
Digital Signature:	I authorize the above listed suppliers and banks to release information to Pet Food Source for the purpose of setting up credit terms.
Confidential VISA / MASTERCARD Authorization
Select Credit Card:
Name on Card:
Expiration Date (Month):
Expiration Date (Year):
Digital Signature:	I authorize Pet Food Source to keep on File, for the explicate purpose to pay the applicable fees associates with my account. This authorization expires one year after authorization date. Renewal of authorization is required on the anniversary of this date.
Enter code visible in the image *

Date / Time

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Welcome

September 2010