Microgram Systems
Please select FILE then PRINT from your menu bar to print out this application form. Or you can download the MS Word format - credit.doc of this form. Our fax number is (604) 683-7990. Thank you. Credit Application |
| Type of Account applying for: | _ Net 15 | _ Net 30 |
| Requesting $ ______________________ | ||
| Company Name: | ____________________________________________ |
| Other Trade Name: | ____________________________________________ |
| Address: Street | ____________________________________________ |
| City: _______________ Prov. ___________ Postal Code: ___________ |
| Phone no. ___________________ | Fax no. _____________________ | ||
| PST no. ____________________ | GST no. ____________________ |
| Shipping Address: ______________________________________________ | |
| Email Address:__________________________ |
| Company Profile | |||
| Ownership: | _ Sole Proprietorchip | _ Partnership | _ Limited Company |
| _ Subsidiary - Parent Company Name: __________________ | |||
Business Type: ______________________________________________ |
| Number of Years in Business: ___________________________________ |
| Attached Recent Financial Statement (Audited Perferred) |
| Bank Information | ||
| Bank Name: __________________________________________________ | ||
| Address: Street ________________________________________________ | ||
| City: ______________ Prov. _____________ Postal Code: _____________ | ||
| Phone No. (____)_________________ Fax no. (____)_________________ | ||
| Account Number: _____________________________ | ||
| Loan Number: _______________________________ |
| Credit References Name: _________________________________________ |
| Phone: _________________________________________ |
| Name: _________________________________________ |
| Phone: _________________________________________ |
| Name: _________________________________________ |
| Phone: _________________________________________ |
| Key Company
Personnel State full names of company principals, home address and titles. |
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| Name: _______________________ | Title: _____________________ | |
| Address:
_______________________________________________ |
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| Name: _______________________ | Title: _____________________ | |
| Address: _______________________________________________ | ||
| Key Company Contacts |
| Accounts Payable _______________________________________ |
| Purchasing Manager ____________________________________ |
| Agreement The undersigned certifies that the information supplied in this credit application to be true and affirms that any credit terms are extended upon the basis of such information. The undersigned consents to the obtaining of credit information as may be required at any time in connection with the credit hereby applied for or any renewal or extension thereof and the disclosure of any credit information concerning the undersigned to any credit reporting agency or to any person with whom the undersigned has or proposed to have financial relations. The undersigned hereby grants to MicroGram Systems (Canada) Ltd. ("MicroGram") a security interest in all goods sold by MicroGram to the undersigned and the proceeds thereof (the "Collateral") to secure payment of all debts and liabilities, present or future, direct or indirect, absolute or contingent, matured or not at any time owing by the undersigned to MicroGram (the "Obligations"). Default in payment or performance of any of the Obligations or default under any agreement or document evidencing any of the Obligations shall be a default hereunder whereupon all Obligations shall be due and payable forthwith without notice to the undersigned, and MicroGram shall thereupon have the rights and remedies of a secured party under the Personal Property Security Act, 1989. The Debtor agrees that all proceeds of the Collateral shall be held in trust by Debtor for MicroGram. Authorizationd Signature:
___________________________ Date: _______________
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