Independents Choice Distribution

Events

Credit Application

Company Name: Previously Known as: Company Address: (Street, City, Province) Postal code
E-mail:	Own Lease

Landlords Name:
Landlords Address:
Amount of Credit Requested Per Week:
How long in Business: Yrs Months:
Phone: Fax: Cell:
PST#: GST#: Band#:

Credit References: (When listing Credit References Please give us Suppliers with whom you have dealt with for one year or more, preferably local. A. Suppliers Name: Address: Phone: B. Suppliers Name: Address: Phone: C. Suppliers Name: Address: Phone: Banking Information: A. Name of Bank: Address: Phone: B. Name of Bank: Address: Phone: Principal Owner's Information:
Owners Full Name: Last:
First:	Middle:
Spouse:
Current Address:
Previous Address:
Telephone Numbers:	Fax: Cell:
Previous Employment:
Residence Status:	Owns Rents
Length at Present Address:	Years Months
Landlords Name:
Landlords Address:

Credit References:	Personal (if operating less than 1 year)
Company:
Address:
Telephone:
Account Number:

List any additional information that would clarify your credit application:

Applicant Signature - I hereby Authorize Independents Choice Distribution to investigate my
Credit History in Order to approve Credit for my account.

Signature: Date: