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Applicant Information
First Name
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Last Name
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Title
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Phone Number
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Email
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Company Information
Company Name
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Street Address
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Province
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Postal Code
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Type of Business
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Years in Business
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PST #
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GST #
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Tax Number
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Previous Address (if less than two years)
Street Address
City
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Postal Code
Banking Information
Bank Name
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Contact Name
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Phone Number
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City
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Province
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Postal Code
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Business References
Company Name
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Street Address
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City
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Province
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Postal Code
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Contact Name
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Phone Number
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Fax Number
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Email
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Other
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Agreement
All invoices are to be paid 30 days from the date of the invoice
By submitting this application, you authorize Maple Leaf Wheelchair to make inquiries into the banking and business/trade references that you have supplied.
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