Application For Credit Online Form

Application For Credit
ALL INFORMATION PROVIDED IS CONFIDENTIAL
This Application Must Be Completed In Full

The prompt completion and return of this form will enable us to process your order/application as quickly as possible.

• Indicates Required Information

• Registered Name		• Telephone: (Include Area Code)
• Address		• Fax: (Include Area Code)
• City
• Country		• State/Prov
• E-mail		• PC/Zip
• Web Address

The following information is required.
In Canada:

P.S.T.#

G.S.T. #

The following information is required.
In USA:

I.R.S. #

Please provide, attached under separate cover (as a word document or in pdf format), on Company Letterhead the following information and send to primary@primaryfluid.com.
• Bank Name and Contact Information
• 3-4 Trade References including telephone and fax numbers

The following is required for invoicing.
Accounts will be processed with the acceptance of invoices by fax or email only.
To avoid duplication problems, there will be no follow up invoice sent by mail.

Name and Phone of Accounts Payable Contact:

• Accounts Payable Contact

• Accounts Payable Phone

Please provide the following information and select your preference, for receiving invoices.

• Email Address in Accounting Department		if this is your preference please check
• Fax Number in Accounting Department		if this is your preference please check
• Email Address for shipping notification

All information above is true and complete. The applicant agrees to the terms of credit and that all accounts are due and payable within 30 days of the date of the invoice unless otherwise stipulated in writing and that a service charge of 2% per month will be paid by the customer on all amounts over these terms, starting at 60 days.

• This form has been completed by: a Signing Officer for the above mentioned company.

I have read and understand the terms above and agree to the terms. (This must be checked off or the form will not be processed.)

As an alternative form of payment we also accept VISA, MasterCard, Discovery and American Express.