Vendor Certification Application Form

General

Legal Company Name: Contact Name:
Telephone:
E-mail: Fax:

Mailing Address:

Street: City:
Province: Postal Code:

Payment Address - if different from above

Street: City:
Province: Postal Code:

Type of Business -

Manufacturer:
Manufacturer's Agent
Wholesaler
Dealer
Retailer
Distributor
Contractor
Other (Explain)

Ownership:

Propietorship
Partnership
Limited Company
Incorporated
Registered
Subsidary
Branch

Number of years in business:
Number of employees:

Will goods be supplied from the above address?
Yes
No

Are you able to perform repair on any of the equipment you supply?
Yes
No

Financial:

Gross Annual Sales:
Bank Reference:

Product Details:
Please list materials, articles and equipment you wish to quote/tender on:

Please list services, repairs etc. you are capable of supplying:

References (List 3):

Reference 1

Name of Company:
Contact Person:
Telephone Number:
Goods/Services provided:

Reference 2

Name of Company:
Contact Person:
Telephone Number:
Goods/Services provided:

Reference 3

Name of Company:
Contact Person:
Telephone Number:
Goods/Services provided:

Date of Application

Name and title of person making application