propaneplus.ca

Identification	* Required Fields
* Business Number : * Business Name : * Address : * City : * Province : * Postal Code : * Phone # : Fax # :	* Type of business : * Owner's Name : Payables Contact : Website : * How many years in business at this address? : Purchase Order Required : Yes No Email :
Banking Information
* Bank Name : * Address :	Account No. : * Contact : * Phone # :
Supplier Information
Name : City : Phone # :	Province Fax # :
Name : City : Phone # :	Province Fax # :
Name : City : Phone # :	Province Fax # :
Director or Manager
* Name : * Position :	* Phone # :
Credit Card Information
Type of credit card : Name as it appears on card : Credit Card Number : Expiration Date : Security Code (see back of card) : Payment method : One time Monthly Commentaire:
Authorization
The buyer and/or officer and/or shareholders hereby authorize the salesperson or mandatory to obtain or exchange any pertaining information requestedby the firm in order to establish solvency. It also encloses any concerned persons to give entirely and with diligence any pertaining information requested and discharges them of any responsibility to the effect of this information.
* Check box to confirm request

Commercial Account Request Form New Account