Financial Services Application
Please complete this form, print, sign and fax it to:(514) 344-6446. Thank You

Company Name: E-Mail/Internet Address:

Enter your street address here.
Address: (line 1) If the address does not fit on line one, continue on line two
(line 2)  

City: Province: Postal Code:

Enter your shipping address here if it is different from the one above.
Address: (line 1) If the address does not fit on line one, continue on line two
(line 2)  

City: Province: Postal Code:

A/P Contact
Name: Title: Telephone Number:
() -
Fax Number: () -  

Business Structure
Corporation  Other: Credit Line requested: $
Years in Business:  Province of Incorporation: 
Subsidiary Branch/Division?
YesNo
If yes, Name/Address of Parent:
Has businees oficer filled for Bankruptcy?  YesNo Do you want a Lease Line of Credit established  YesNo
Lease Term: Do you use P.O.s?YesNo
Purchase Option:1$ FMV 10%  Other:

Name of Principals
President: Vice-President:
First: Last: First: Last:

Chief Financial Officer: Controller:
First: Last First: Last:

Bank and/or Lender References
Enter Bank reference here.
Name:  Phone: () -
Address:  Account Number: 
Contact:  Type of Account: 
Enter second reference here.
Name:  Phone: () -
Address:  Account Number: 
Contact:  Type of Account: 

Permission is herewith granted to obtain credit information from all listed references including my bank, as well as, to investigate the above mentioned Purchaser. All financial information submitted in support of this credit application is true and complete in all respects. I understand that Insight Canada Inc’s (hereinafter called “Insight”) terms are net 30 days from the date of invoice. Furthermore, I understand that my orders will not be shipped if my account is past- due, and that collection fees (including legal fees), and related costs are my responsibility in the event of my non-payment. Interest on past due accounts will be charged at the rate of 2% per month (24% per annum). I /We hereby authorize Insight to obtain personal and credit information about us and/or our company from any source. Any legal proceeding with respect to any dispute will be tried in a Montreal, Quebec court of competent jurisdiction by Judge. By my /our signature(s) below, I/We acknowledge in this credit application, Insight’s intent to obtain this information. I/We make this application on behalf of the above mentioned company and understand that the information contained within is for the explicit use of Insight and its subsidiaries. By executing this credit application, I/we on behalf of the Purchaser do hereby acknowledge having read and understood the foregoing terms and conditions outlined hereinabove and do, therefore, bind and oblige the Purchaser to the due fulfillment of same.
Name: Title:
First: Last:
Signature: Date: