Elliott Coach Lines - Fuel Resale

Full Name *
Address *
Postal Code *
Phone Number *
Fax Number:
Email:
Affiliated With:
Type of Business:
If Other Please Specify:
Type of Products Sold:
Number of Employees *
Person in Charge *
Business is a *
If Partnership, names of Principals:
If Corporation, date incorporated:
Accounts Payable Contact *
Purchase Order Number Required *
Term of Blanket:

Financial Information ( if applicable )
Sales Volume Last Year:
Estimated Net Worth:
Have you ever been denied credit:
If yes, please explain:
Have you ever declared bankruptcy, or been a party of bankruptcy proceedings:
If yes, please explain:
References ( Bank and Trade )
Bank *
Bank Address *
Phone Number *
Person to Contact:
Note that three (3) Trade References are required
Trade References
Name *
Phone *
Address:
Fax Number:
City:
Province:
Code:


Name *
Phone *
Address:
Fax Number:
City:
Province:
Code:


Name *
Phone *
Address:
Fax Number:
City:
Province:
Code:

Credit Requirements
Approximate monthly credit requirements from us
Please list all authorized purchasing agents:
1.
2.
3.
4.

Upon credit being granted, a signature will be required to verify agreement with the following terms.

Net 30 days from date of invoice.

2% per month on outstanding balances ( 24% per annum )