Account Request

All fields with a * are required.

BANKING INFORMATION

Banking Institution*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Account Number*

Contact Name

First Last

Contact Phone Number

SUPPLIER #1

Information on 3 suppliers is required.

Company Name*

Contact*

First Last

Phone Number*

E-mail address*

Fax Number*

SUPPLIER #2

Company Name*

Contact*

First Last

Phone Number*

E-mail address*

Fax Number*

SUPPLIER #3

Company Name*

Contact*

First Last

Phone Number*

E-mail address*

Fax Number*

CREDIT CARD INFORMATION

Type of card*

Credit card Number*

Expiry Date*

Security Code

CONSENT & AUTHORIZATION

I/We presently and as long as we are dealing with the above mentioned suppliers, authorize consent to the credit bureau to obtain credit information from our bank and suppliers with regards to the opening and/or revision of our account with Impekk.*

I Agree

Name*

First Last

Title

Note: Account will be opened as soon as a proper credit verification has been completed. You will be contacted once the process is finalized.

Note: You will be contacted once the process is finalized and the account is opened.

Canadian Anti-Spam Legislation (CASL) requires us to have your express consent, by submitting this form implies that you are giving Impekk your consent for us to send you relevant information. You may withdraw your consent at anytime by using the un-subscribe link at the bottom of the emails we send you or by sending an email to postmaster@impekk.com. For additional information, please contact Impekk at 1855 Hymus, Dorval, PQ, Canada, H9P 1J8. Phone: 514.685.2707 or 800.363.4979. A link to unsubscribe will always be available at the bottom of each email if you wish to be removed from our list.

New Account Request

NEW ACCOUNT - CREDIT APPLICATION FORM

COMPANY INFORMATION

BANKING INFORMATION

SUPPLIER #1

SUPPLIER #2

SUPPLIER #3

CREDIT CARD INFORMATION

CONSENT & AUTHORIZATION