Application For Credit

Application For Credit
This Application Must Be Completed In Full

• Required Information

• Registered Name		• Tel: (Include Area Code)
• Address		• Fax: (Include Area Code)
• City
• Country		• State/Province
• E-mail		• Postal/Zip Code

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 on Company Letterhead the following information.
• Bank Name and Contact
• 3-4 Trade References
• Phone & Fax
• Please attach under separate cover (as a word document or in pdf format) and send to: primary@primaryfluid.com

ALL INFORMATION PROVIDED IS CONFIDENTIAL

The following is required for invoicing.
Accounts will be processed with the acceptance of invoices by fax or e-mail 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 and indicate your preference to receive invoices.

• E-mail Address (in accounting department)		if this is your preference please check
• Fax Number (in accounting department)		if this is your preference please check

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

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

• This form has been completed by:

All information above is true and complete. The applicant agrees to the terms of credit and that all accounts are due and payable within 30 days of the date of the invoice unless otherwise stipulated in writing and that a service charge of 2% per month will be paid by the customer on all amounts over these terms, starting at 60 days.

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.)