Credit Application The following is an application to open an account with Great Plains Cresting.

Company Name:

Address:

City: Province/State:

Postal Code/Zip code:

Phone Number: Fax:

Year Business Started:

Were you referred by someone? No Yes, by who?

Contact Name:

Shipping Address (if different from above):

Billing Address (if different from above):

Billing Method:

Please Choose one: Credit desired credit limit: Credit Card

We require all customers to have a credit card  number on file for at least their first year,
should payment be a problem, we will charge any outstanding balances onto the credit card.

                                        Mastercard               Visa

Credit card number:      Expiry:  

Name on the credit card:  

Shipping preferences: 

Ups ....... prepaid / collect ......your account no:
Purolator .......prepaid / collect ......your account no:
xpost .........prepaid only
cheapest
other ......your account no:

References:

Please provide us with 3 company credit references:

Company Name:

Address:

Phone: fax:

Contact Name:

Company Name:

Address:

Phone: fax:

Contact Name:

Company Name:

Address:

Phone: fax:

Contact Name: