Business Credit Reports

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Company Information

Company Name

Trade Name

Address

City

State/Province

Zip/Postal Code

Country

Billing Address

Billing City

Billing State/Province

Billing Zip/Postal Code

Billing Country

Main Phone Number

Main Fax Number

Business Start Date

Place of Incorporation or Registration

Parent Company and/or Subsidiaries

Ownership (Corporation/Partnership/Sole Proprietor/ Other - Elaborate)

Years Under Current Ownership

Number of Employees

Type of Business

Number of Locations

Type of Account (Credit/COD)

Annual Sales (most recent fiscal year)

Fiscal Year End Date

Has the Business ever been party to any claim or lawsuit? (Yes/No)

Do the Business's principals currently owe any back taxes, been in receivership or declared bankruptcy? (yes/no)

Does the Business own or rent its facilities? (own/rent)

If renting, Landlord's name

if renting, landlord's phone number

AWSA No. (if applicable)

AWSA No. (if applicable)

Contact Information

First Name

Last Name

Title

Email

Phone

Accounts Payable Contact Information

Name

Email

Invoice Delivery Method (Email/Mail/Other)

If Email, Email Address

If Mail, Mailing Address

If Other, elaborate

Tax Exemption Information

PST Exempt (Yes/No - if yes, provide exemption numbers or exemption certificates)

Carbon Tax Exempt (Yes/No - if yes, please provide exemption certificates)

Pesticide Applicators License

Pesticide Applicators License No. (if applicable)

Name

Province

Pesticide Applicators License No. (if applicable)

Name

Province

Pesticide Applicators License No. (if applicable)

Name

Province

Pesticide Applicators License No. (if applicable)

Name

Province

Pesticide Applicators License No. (if applicable)

Name

Province

Private Corporation - Senior Officers

Name

Title

Phone Number

Name

Title

Phone Number

Name

Title

Phone Number

Partnership - Partners

Name

Title

Phone Number

Name

Title

Phone Number

Name

Title

Phone Number

Trade References - Major Suppliers

1. Name

1. Phone Number

1. Email

1. Fax

2. Name

2. Phone Number

2. Email

2. Fax

3. Name

3. Phone Number

3. Email

3. Fax

4. Name

4. Phone Number

4. Email

4. Fax

Credit Requested

Requested Amount

Requested Payment Terms

Supporting Documentation

Please upload the most recent two (2) months bank statements if you are requesting a credit limit of $100,000 or more. If you are PST Exempt or Carbon Tax Exempt, please upload copies of your exemption certificates as well.

Click the Browse / Choose Files button above to select the files you want to send. Then click the Upload button.
Please keep individual file sizes to 4MB or less.

Uploaded Documents

Terms

Terms & Conditions

I accept the above terms.

Please Sign Below

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Submit the Request

By clicking 'Submit', I/We authorize Veseris Canada or its agent to obtain a credit report for the purpose of establishing, maintaining or enforcing a credit relationship. Upon approval of credit, I/We agree to pay our account according to the terms granted and I/We acknowledge that I/We have read and fully understand this application.