Business Credit Application

Business Info
Are you a corporation?
- Corporation
Name of Business*
Year of Incorporation*
Principle/Owner*
Date of Birth*
MM
DD
YYYY
Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
HST #*
Amount of Credit Requested*
PO Required*
- Yes
- No
Contact for Account
Name*
First Middle Last
Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Business Phone*
Cell Phone
Position*
Since*
Month
Day
Year
Trade Reference 1
Name of Reference*
Account # or Name*
Contact Name*
First Last
Phone*
Ext
Trade Reference 2
Name of Reference*
Account # or Name*
Contact Name*
First Last
Phone*
Ext
Trade Reference 3
Name of Reference*
Account # or Name*
Contact Name*
First Last
Phone*
Ext
CREDIT TERMS - NET 20 DAYS - Final Credit Terms to be granted and approved by Primemax Energy Inc.
Email Statements
- Sign up for Email Statements.
Interest Agreement*
- I understand past due accounts may be subject to interest charges at a rate of 2% per month, 24% per annum.
Information is Complete*
- I agree that the information given above is accurate and complete.
Credit Checks*
- I authorize PRIMEMAX ENERGY INC. to conduct credit checks or obtain any information required to establish or verify my financial standing for the purpose of this credit application. I also agree to comply with the terms and conditions of sale as stated above.
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Comments
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In compliance with the Privacy Act, this information is not distributed to any other party, or used in any other way, except for the purpose stated above. This information is considered private and confidential.

Business Credit Application

Business Info

Contact for Account

Trade Reference 1

Trade Reference 2

Trade Reference 3