*  Your name : Your title : *  Your email : *  Name of your company : Doing business as (if name is diffrent) : *  Accounts payable contact : *  Puchasing contact : *  Type of business : *  Number of years in business : *  Number of employees : Language : French English Monthly statement required ? Yes No Do you accept delivery at a later date for back order products? : Yes No I want to receive your newsletter or promotion by email

*  Address : *  City : Country : Choose a country   Please choose a country Province / State / Region : Please choose a province / state *  Postal code / Zip : *  Phone Number : Ext Fax :

Address : City : Country : Choose a country   Please choose a country Province / State / Region : Please choose a province / state Postal code / Zip :

Purchase order number required? : Yes No *  Amount required : $ Have you ever had an account with us? : Yes No If YES, provide old number : Merchandise for resale? : Yes No If YES, provide PST number : *  Potential annual purchase volume : $ Wich merchant in your area do you wish to buy from? : Find a store

*  Financial Institution : *  Manager : *  Account Number : *  Address : *  City : Country : Choose a country   Please choose a country Province / State / Region : Please choose a province / state *  Postal code / Zip : *  Phone Number : Ext

Company * 1. Contact Name Phone and Fax Phone Ext Fax 2. Phone Ext Fax 3. Phone Ext Fax

By submitting this form, we authorize Novexco Inc. and/or Equifax to request any credit verification you will deem necessary when of opening our account and at any time you will deem necessary thereafter. We authorize you to provide credit information with any authorized person.