Online Account Form

Section 1
Company Name
P.S.T. Exemption #  
Address  
City  
Province  
Postal Code  
Phone Number  
 Fax Number  
Email (mandatory field)*  
URL of your web site  

Section 2
Business Commencement Date
Nature of Business  
Number of Employees  
Current year's Revenue  
Business Type  
Please indicate any other business name  
Previous Affiliations  
President / Owner's name  
S.I.N  
Address  
Phone #  
Fax #  
Account Manager / Controller  
A/P Contact  
Bank Name  
Account #  
Address  
Phone #  
Fax Number  

Section 3

Please Provide at least THREE trade references
1. Company Name  
Contact   
Address  
Phone #  
Fax #  
Terms  
Monthly Credit Limit  
2. Company Name  
Contact  
Address  
Phone #  
Fax #  
Terms  
Monthly Credit Limit  
3. Company Name  
Contact  
Address  
Phone #  
Fax #  
Terms  
Monthly Credit Limit  

I authorize Samtack Computer Inc. to obtain such factual and investigate information regarding me from others as permitted by law. To furnish to her customer credit grantors and credit bureaus particulars of the credit application and subsequent credit experience if applicable and to return this application for Samtack Computer Inc.'s records. I agree to pay Samtack $25.00 for each of any returned or bounced cheque(s)
Completed by 

Title 

Date