Customer Access

Credit Request Form



» Customer Information

Legal Business/Corporate Name *

Mailing Address *

City *

Province / state

ZIP *

Country

Contact *

Telephone No. *

Fax No.

E-Mail Address *



» Billing Information (if different from above)

	Same Information

Legal Business/Corporate Name

Billing Address

City

Province / state

ZIP

Country

Contact

Telephone No.

Fax No.

E-Mail Address



» Description of Business

Nature of Business

Date Incorporated/Organized/Acquired

Type of Entity

CAN Federal Tax ID #

GST #

QST #

HST #

US Federal Tax ID #



» Bank Reference

Name

Full Address

Telephone No.

Fax No.

E-Mail Address

Loan No.

Account No.

Bank Officer



» Trade References

› First reference

Name

Full Address

Telephone No.

Fax No.

E-Mail Address

Account No.

Contact Person



› Second reference

Name

Full Address

Telephone No.

Fax No.

E-Mail Address

Account No.

Contact Person



› Third reference

Name

Full Address

Telephone No.

Fax No.

E-Mail Address

Account No.

Contact Person



» CREDIT AMOUNT

Amount of credit requested:



»Additional Information

Business Terminal *

Sales Contact



AUTHORIZATION

I/We hereby authorize the party/parties to whom this application is made to investigate my/our financial responsibility and credit worthiness. I/We further certify that all statements made in this application are given for the express purpose of obtaining credit from Logistec Corporation which grants credit in reliance thereon and, further, that they are true and for the purpose of establishing a line of credit for the above mentioned company. Verification may be obtained from any source named in this application or from a recognized reporting agency.

*

Please be advised that you may be contacted for the purpose of obtaining additional authorization for the request of banking information.



Name *

Title *

	Date: 11/29/2023