Note: This form can be completed either by hand and faxed to RobotShop or submitted electronically (as an attachment). You are free to add lines where needed.

Contact Information

Company: ______

Address: ______

______

Name: ______

E-mail: ______

Telephone: ___(____)______Extension:______

Fax: ______

Website ______

General Information

Date Business Started: ______

Description of business: ______

______

______

Products you are interested in: ______

______

______

Estimated Annual Purchase ______

Federal Tax ID Number: ______

Sole proprietorship: / Partnership: / Corporation: / Other:
Retail Only: / Web Only: / Retail and Web: / Other:

Submit to: The RobotShop Support Center (as file attachment) or by Fax: 450-420-1447

BANK REFERENCE

Business Address

City: State / Province: ZIP Code:

Telephone: Fax: E-mail:

How long at current address:

Bank Name:

City: State / Province: ZIP Code:

Telephone: Fax: E-mail:

Type of account / Account number
Savings
Checking (CAD)
Other (USD)

BUSINESS / TRADE REFERENCES

Company name:

Address:

City: State / Province: ZIP Code:

Telephone: Fax: E-mail:

Type of account: Savings Checking (CAD) Other (USD)

Company name:

Address:

City: State / Province: ZIP Code:

Telephone: Fax: E-mail:

Type of account: Savings Checking (CAD) Other (USD)

Company/Applicant: hereby authorizes the release of information from trade references, banks or credit agencies, necessary for RobotShop Inc. to extend credit.

AGREEMENT

1.  I hereby certify that this information is complete and accurate to the best of my knowledge and belief. Applicant’s signature attests to financial responsibility, ability, and willingness to pay all invoices in accordance with RobotShop Inc. credit terms. Applicant agrees to notify RobotShop Inc within 30 days of any change of address in writing.

2.  By submitting this application, you authorize RobotShop Inc to make inquiries into the banking and business/trade references that you have supplied.

3.  In the event of default, the applicant agrees to pay all reasonable collection, legal and court cost associated.

Authorized Officer:
Date: / RobotShop Inc. Officer:
Date: