Residential account

1Credit reference

2Employer & occupation

3Financial institution

4Special authorization

Name of vendor at PCDupuis*
I have a PO/order number?*
- Yes
- No
PO/order number*
Credit reference for opening an account
Last name*
First name*
Last name of spouse
First name of spouse
Date of birth*
DD slash MM slash YYYY
Social insurance number
Billing address*
address City Postal code
Use an other address for delivery
- Use an other address for delivery
Address delivery
Address City Postal Code
Number of years at this address*
Please enter a number greater than or equal to 0.
Owner or tenant*
Home phone*
Cellular phone*
Email address*

Financial institution
Name of financial institution*
Please make sure you complete the authorization document
and send it back to us by email, fax or mail.
Address*
Address City Postal Code
Phone*
Account number*

Special authorization
I authorize Pierre et Camille Dupuis In. to make a credit check on me and obtain any information which the creditor will consider relevant.

The present also establishes an authorization to communicate with a third party and to use this information for all purposes which Pierre et Camille Dupuis will consider useful. I also authorize all third parties concerned to supply to Pierre et Camille Dupuis all information asked.

THE PAYMENT OF PC DUPUIS IS NET 30 DAY AFTER DATE OF INVOICE.
You full name*
First name Last name
Your phone number*
Your initials*
Signature*
I have read and accept the conditions and authorization mentionned above.
Email
This field is for validation purposes and should be left unchanged.

Credit reference for opening an account