Client Register | PCAM

PartSource Commercial Account & Credit Application

Store & Account Control Data

Store Number*

ASM Name*

Store Phone #*

Pay Type*

Business is a*

Other

Account Type*

Nature of Business*

Date Business Opened (YYYY/MM)*

Customer & Business Information

BILLING ADDRESS

Phone #*

Legal Business Name*

Operating As*

Bill To*

Address 1*

Address 2

City*

Province*

Postal Code*

Country*

Fax#

Email Address*

Supporting Documents

SHIPPING ADDRESS

Same as Billing

Phone #*

Address 1*

Address 2

City*

Province*

Postal Code*

Country*

Fax#

Business Principals/officers

PRINCIPAL 1

Full Name*

Title/Position*

Phone Number*

Address 1*

Address 2

City*

Province*

Postal Code*

Country*

Fax #

PRINCIPAL 2

Full Name

Title/Position

Phone Number

Address 1

Address 2

City

Province

Postal Code

Country

Fax #

Tax Exemption Information

YES

CORE TAX

GST/HST# Enter GST/HST#

PST

PST#

(For MB/SK/BC only, and on the purchases for resale only)

QST

QST #

Credit Limit Request

Approx Monthly Sales*

Suggested Credit Limit

Requested Credit Limit

Account Terms & Conditions

I Agree with Terms & Conditions

Full Name*

Title*

Date*

Authorized Signature*

Personal Guarantee

YES

In consideration of PartSource opening a charge account and extending credit to the Account Holder, the undersigned hereby agrees and acknowledges that he/she is jointly and severally liable for the payment of all goods and services purchased from PartSource under the same terms and conditions of the charge account which apply to the Account Holder.

Full Name*

Phone #*

Date*

Signature*

Home Address (Guarantor)

Address 1*

Address 2

City*

Province*

Postal Code*