Credit Application

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Corporate Information:
Company Name:	Company Address:
City/Town:	Province:	Postal Code:

Owner Name:	Owner Title:
Phone:

Owner Name:	Owner Title:
Phone:

Owner Name:	Owner Title:
Phone:

Owner Operator:
First Name:	Middle Name:	Last Name:
Title:
Address:
City/Town:	Province:	Postal Code:
Residence phone:
Business phone:
Cellular phone:

Date of Birth: Day Month Year

Driver's License Number:
Social Insurance Number:
Employer:	Years in Business:
GST Number:	PST Number:
Accounts Payable Contact:
Bank:	Branch:
Contact for Bank:	Phone for Bank:

Please List Three Supplier References:
Company:	Contact:
Phone:

Company:	Contact:
Phone:

Company:	Contact:
Phone:

Amount of Credit Required: $

In consideration of your agreeing to grant the undersigned credit, the undersigned agrees as follows: To pay for all purchases net 30 days following the date of purchase. A service charge of 2% per month is chargeable on all past due purchases, calculated from the date which they became due. Provided, however, that the charging of said service charge shall not relieve me of my obligation to any for the purchases when due. Connexion Truck Centre may cancel this charge account at any time without notice. I authorize Connexion Truck Centre and it's assigns to obtain such factual and investigative information regarding me from others as permitted by law. Connexion Truck Centre reserves the right to lien and seek available remedies for all work done within the service shop facilities through the Garage Keepers Act of Manitoba.
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