Print, complete the form and email to sales@orioncomputer.ca.

NEW ACCOUNT/CREDIT APPLICATION FORM

COMPANY PROFILE

Company Name: __________________________________________________________________________

Business Address: ________________________________________________________________________

Telephone: __________________________________ Email: ______________________________________

Date Business Established: _____________________

Owner: _____________________ Telephone: _____________________ Email: _____________________

Social Insurance Number: _____________________ % of Ownership: _____________________

BANK REFERENCE

Bank Name: _____________________ Address: _____________________

Telephone: _____________________ FAX: _____________________Contact: _____________________

Account Number: _____________________ Transit#: _____________________

CREDIT REQUEST

Requested Credit Line: _____________________

Requested Terms: _____________________

TRADE REFERENCE

Company Name: _____________________ Contact: _____________________

Telephone: _____________________ Address: _____________________

I hereby certify that the information contained herein is true and correct, and grant vendor permission to verify all information. Further I hereby authorize the bank and trade references listed in this application to release the information necessary to assist ORION COMPUTER & ELECTRONICS in establishing an account for our company.

Authorized Signature: ____________________ Title: ____________________ Date: ____________________