1. Company Information

Company Name

Street

City

Province

Postal Code

Country: Canada (Required)

Email Address

Phone Number

Fax Number

PST/GST Exemption Number

2. Company Details - Principal Owners/Shareholders

Person 1

Name

Street

City

Province

Person 2

Name

Street

City

Province

3. Bank Information (fill this section out OR section 5 - credit card authorization)

Bank Name

Street

City

Province

Postal Code

Phone Number

Fax Number

Name of Contact

4. Other Contacts

Accounts Payable Contact Name:

Accounts Payable Contact Email Address:

Purchasing Contact Name:

Purchasing Contact Email Address:

5. Credit Card Authorization (not applicable for net 30 days customers)

VisaMastercard

Name on Card:

Card Number:

CVV Number:

Expiry Date:

6. Type of Business (check all that apply)

HospitalPhysiotherapistRehab CentreOrthotic/Prosthetic ServiceShoe/Foot OrthoticsDistributorSports MedicineRetailerOther

7. Invoices

How would you like to receive invoices?

EmailFax

Where would you like to receive invoices? (email address or fax number):

Name of person(s) receiving invoices:

8. Packaging

What type of packaging would you like to receive your products in?

RetailNon-retail - bags

9. Trade References - required for both credit card and net 30 terms

Please provide at least 3:

Reference 1

Company Name:

Account number:

City:

Province:

Fax Number or email address of trade reference contact person:

Reference 2

Company Name:

Account number:

City:

Province:

Fax Number or email address of trade reference contact person:

Reference 3

Company Name:

Account number:

City:

Province:

Fax Number or email address of trade reference contact person:

Reference 4

Company Name:

Account number:

City:

Province:

Fax Number or email address of trade reference contact person:

Please note: $50.00 minimum order required. Credit terms are net due in 30 days. Orders may be held for overdue accounts. Any orders placed by new accounts will not be shipped until we receive your completed credit application forms. We cannot process your application unless you fill out all necessary fields - to avoid delays, please ensure either your banking or your credit card information is complete before submitting.