First Name
Last Name
Email
Company
Adresse
City
Postal Code
Phone (Numeric value only)
Fax (Numeric value only)
Industry Accommodation and food services Agriculture / fishing and hunting Arts / entertainment and recreation Construction Educational services Finance and insurance Forestry and logging Health care and social assistance Manufacturing Mining and quarrying (except oil and gas) Oil and gas extraction Other Professional / scientific and technical services Public administration Real estate and rental leasing Telecommunication Transportation and warehousing Utilities Waste management and remediation services Wholesale trade and retail trade Management of companies Information and cultural industries
Company Size Less than 25 employees 25 to 99 employees 100 to 249 employees 250 to 499 employees 500+ employees
In business since Less than 6 months 1 to 5 years 5 to 10 years 10 to 15 years 15 years and more
Credit line required Cash 1000$ 5000$ 10 000$ 15 000$ 25 000$ 50 000$ 100 000$
Shipping address (if different)
Your Carrier Yes No
Account # (Carrier)
Special Instructions? Yes No
Special Instructions (if applicable)
Have you, or any other division, already dealt with SPI before ? Yes No
Under which name ?
Accounts Payables - Contact Name
Accounts Payables - Email
Accounts Payables - Phone
Controller - Contact Name
Controller - Email
Controller - Phone
How did you hear about us ? Recommended by a friend, colleague, or partner Company's reputation Sales representative Website Advertising, social media Event, webinar Tender
Signature
Date
Comments
ACTING ON BEHALF OF THE COMPANY REQUESTING CREDIT, THE DULY AUTHORIZED UNDERSIGNED AGREES TO THE FOLLOWING : I hereby request a credit margin with SPI and/or its affiliated companies in accordance with the preceding rules I have read this document and the attached sales terms and conditions, I fully understand and accept these terms I hereby authorise SPI and/or its affiliated companies to obtain from any person and keep all personal information contained in this request. I also hereby authorise SPI and/or its affiliated companies to divulge and make available all information concerning the company I represent to lenders, personal credit companies as well as to any parties related to this request for the duration of the present and until such time of the request has been fully accepted and activated.
By signing this document, I hereby accept the terms and conditions of SPI and/or its affiliated companies and I hereby declare all claims and statements made in this document are true, complete, and accurate.