*(denotes required field)

Name of Business *

E-Mail Address: *

E-Mail Address again: *

Please enter your E-mail Address a second time.

Address *

City *

Province *

Postal Code *

Telephone Number

Fax Number *

Name of Owner *

Type of Business *

Please Supply the name and phone number of 3 current credit references (Canadian only)

Number of Years in Business *

Canadian Credit Reference *

Canadian Credit Reference *

Please provide us with the name, address, and telephone number of your bank

Bank *

As the owner of above business, I acknowledge the Kelsea Credit terms and agree to pay all balances owing within 30 days. If my account goes over 30 days, I agree to pay 1.5% interest/month on the balance

I acknowledge and agree *