Residential Credit Application

Contact Information
Name*
First Middle Last
Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Fire Code*
Status*
- Rent
- Own
Home Phone*
Business Phone*
Cell Phone
Email
Previous Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
MM slash DD slash YYYY
Name at Birth
Employer Name*
Position*
Since*
MM slash DD slash YYYY
Bank Reference
Name of Bank*
Account Number*
Address*
Contact Name*
Phone*
Ext.*
Sole Propietor Only
If Corporation, use Business Credit Application
Business Name
Years in Business
Mailing Address
Street Address City State / Province / Region ZIP / Postal Code Country
Phone
Cell
Fax
Email
HST Number
Trade References
Address
Company
Phone
Address
Company
Phone
Address
Company
Phone
CREDIT TERMS - NET 30 DAYS - FINAL CREDIT TERMS TO BE GRANTED AND APPROVED BY PRIMEMAX ENERGY INC.
Email Statements
- Sign up for Email Statements.
Interest Agreement*
- I understand past due accounts may be subject to interest charges at a rate of 2% per month, 24% per annum.
Information Confirmation*
- I agree that the information given above is accurate and complete.
Credit Checks*
- I authorize PRIMEMAX ENERGY INC. to conduct credit checks or obtain any information required to establish or verify my financial standing for the purpose of this credit application. I also agree to comply with the terms and conditions of sale as stated above.

In compliance with the Privacy Act, this information is not distributed to any other party, or used in any other way, except for the purpose stated above. This information is considered private and confidential.

Residential Credit Application

Contact Information

Bank Reference

Sole Propietor Only

Trade References