Credit Card Form
In order to be eligible for the payment option of
"
50% Deposit with balance net 30 days
",
please fill out this form and submit it.
Company Information:
Date:
-Day-
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
-Month-
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
-Year-
2003
2004
2005
2006
2007
2008
2009
2010
Name:
Position:
Company:
PST# / Fed.Tax I.D.#:
Address:
City/Prov./State:
Postal/Zip Code:
Phone No. (with area code):
Fax No.:
Email:
Principals:
Year Business Established:
Type of Business:
Bank Information:
Bank Reference:
Phone No.:
Authorization to conduct Bank Credit Check:
Yes
No
Trade Reference 1:
Name:
Phone No.:
Position:
Trade Reference 2:
Name:
Phone No.:
Position:
Trade Reference 3:
Name:
Phone No.:
Position:
It is understood that Moustrak LTD. terms require payment in full within 30 days from delivery of product. It is further understood that failure to follow the above terms may result in cancellation of account.
Company Name:
Owner/Officer Title.: