CONTACT INFORMATION

NAME: *

TITLE: *

EMAIL: *

PHONE NUMBER: *

BUSINESS INFORMATION AS REGISTERED

COMPANY NAME: *

ADDRESS: *

PHONE NUMBER: *

CITY: *

PROVINCE/TERRITORY: *

POSTAL CODE: *

LENGTH OF TIME AT CURRENT ADDRESS: *

TYPE OF BUSINESS: *

CREDIT CARDS ON FILE (REQUIRED - OR PAY BEFORE SHIPPING)

CREDIT CARD NUMBER:

NAME ON CARD:

EXPIRY DATE:

CVV:

* NO CHARGES WILL OCCUR UNTIL WRITTEN/VERBAL PERMISSION IS GIVEN FROM CARDHOLDER *

BANK INFORMATION (BANK TRANSFER)

BANK NAME:

ADDRESS:

PHONE NUMBER:

CITY:

PROVINCE/TERRITORY:

POSTAL CODE:

TYPE OF ACCOUNT:

INSTITUTION NUMBER (3 DIGITS):

TRANSIT NUMBER (5 DIGITS):

ACCOUNT NUMBER (11 DIGITS):

DELIVERY INFORMATION

ADDRESS: *

CITY: *

PROVINCE/TERRITORY: *

POSTAL CODE: *

OPERATION HOURS: *

CONTACT NAME: *

CONTACT PHONE NUMBER: *

DISCHARGING OPTIONS: *

Form ID

Company representative. I hereby declare this information to be true and state I have the authorization to represent the above stated company

NAME/SIGNATURE: *

TITLE: *

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