Credit Application

"*" indicates required fields

Company Name*

Trade name (if different)

In Business Since*

Company is*

Proprietorship

Partnership

Incorporated

Email*

Phone*

Fax

Mailing Address*

Street Address City Province Postal Code

Location Address

Street Address City Province Postal Code

Principals

Name

Title

Address

Bank and Branch Address

Major Suppliers

Company/Name

Credit Limit

Are purchase orders always used?

Yes

Amount of Credit Required*

The undersigned does hereby certify that the information provided above is true and correct and does hereby authorize the firm to whom this application is submitted to obtain such credit reports or other information as may be deemed necessary in connection with the establishment and maintenance of a credit account. This consent is given pursuant to section 120 F of the Personal Information Reporting Act of British Columbia.

The undersigned acknowledges that the terms of sale are Net 30 Days and that a service charge of 2% per month (26.8% annually) will be added on any past due portion of the account.

Sumas Gro-Media Ltd. reserves the right to refuse delivery or service of any kind until full payment has been made on account.

Name of Person Signing below*

Signature*

Personal Guarantee

Applicant Name*

Company Name*

Signature*