Application For Credit

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ACCUDRAW® TOP VALVE ACCU-PULSE PFS Injection Quills ACCU-VENT Corporation Stops
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Application For Credit
ALL INFORMATION PROVIDED IS CONFIDENTIAL
This Application Must Be Completed In Full

The prompt completion and return of this form will enable us to process your order/application as quickly as possible.

Indicates Required Information

Registered Name Telephone:
(Include Area Code)
Address Fax:
(Include Area Code)
City    
Country State/Prov
E-mail PC/Zip
Web Address    

The following information is required.
In Canada:
P.S.T.# G.S.T. #
The following information is required.
In USA:
I.R.S. #    

 

Please provide, attached under separate cover (as a word document or in pdf format), on Company Letterhead the following information and send to primary@primaryfluid.com.
Bank Name and Contact Information
3-4 Trade References with Email Addresses, Phone & Fax Numbers

The following is required for invoicing.
Accounts will be processed with the acceptance of invoices by fax or email only.
To avoid duplication problems, there will be no follow up invoice sent by mail.

Name and Phone of Accounts Payable Contact:

Accounts Payable Contact Accounts Payable Phone

Please provide the following information and select your preference, for receiving invoices.
Email Address in Accounting Department if this is your preference please check
Fax Number in Accounting Department if this is your preference please check
Email Address for shipping notification  


By signing this Application for Credit, I hereby accept the terms and conditions of Primary Fluid Systems Inc. I also, certify that all information above is true and complete. I agree that all accounts are due and payable within 30 days of the date of the invoice and that a service charge of 2% per month is acceptable and will be paid without exception on all amounts over 60 days and before the release of any future orders. Primary Fluid Systems Inc. Terms and Conditions over rule any Terms and Conditions applied by or stipulated on purchase orders from your company unless agreed upon in writing and advance from management of Primary Fluid Systems Inc.

This form has been completed by: a Signing Officer for the above mentioned company.
   


I have read and understand the terms above and agree to the terms. (This must be checked off or the form will not be processed.)

As an alternative form of payment we also accept VISA, MasterCard, Discovery and American Express.