Company Information

Company Name
  
Carrying on business as: (coba) or d/b/a
City
  
State or Province
Zip or Postal Code
   - 
Telephone Number (day)   -  - 
(night)   -  - 
(other)   -  - 
Fax Number -  - 
E-mail Address / Web Site  
Billing Address  
 
Federal I.D. No.  
or Revenue Canada Business No.  
I.C.C. MC No.  
or Provincial Operating License No.  

 Account Contacts / Authorized Personnel
 

Main Contact
    -  -   
Name SS# or password Dollar Limit

Other Authorized Personnel
    -  - 
Name SS# or password Dollar Limit
    -  - 
Name SS# or password Dollar Limit
    -  - 
Name SS# or password Dollar Limit

Bank & Business References

Bank Reference - Required  
Name
  
Street Address
  
City
  
State or Province
Zip or Postal Code
   -
Contact
  
Telephone No.
   -  - 
Fax No.
   -  - 
Account No.(s)

Factoring Company - Optional		  
Name
Street Address
City
State or Province
Zip or Postal Code
   -
Contact
Telephone No.
   -  - 
Fax No.
   -  - 
Account No.(s)

Business Reference 1 - Required 		 
Name
  
Street Address
  
City
  
State or Province
Zip or Postal Code
   -
Contact
  
Telephone No.
   -  - 
Fax No.
   -  - 
Account No.(s)

Business Reference 2 - Required 		 
Name
  
Street Address
  
City
  
State or Province
Zip or Postal Code
   -
Contact
  
Telephone No.
   -  - 
Fax No.
   -  - 
Account No.(s)

Current fuel card and funds transfer service:
  


Customer Detail

Number of Years in business 

Number of units to use service:  Co.