To apply for credit with Master Flo Valve Inc., please provide the information requested below.

1. Company Details

Full Legal Business Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Upload Credit Information Document {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

If you do not have a credit information document, complete the questions below.

Business Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

City {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Province/State {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Postal Code/Zip Code {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Country {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Telephone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Fax Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Website Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Form of Business {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Type of Business {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Years in Business {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Dun & Bradstreet Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Federal Tax ID/Federal Sales G.S.T. Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Provincial/State Sales Tax Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Country in Which Product is Required {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Is Your Company Tax Exempt ? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Attach tax certificate if you answered Yes above {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Country Withholding Tax {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Indicate % withheld if you answered Yes above {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Preferred Currency for Purchases {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Requested Credit Limit {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Expected Monthly Purchases (in currency selected above) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

2. Company Accounts Payable Information

Contact Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Contact Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Contact Telephone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Company References

Upload company references {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Reference #1

Company Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

City {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Transaction Value {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Telephone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Fax Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Reference #2

Company Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

City {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Transaction Value {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Telephone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Fax Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Reference #3

Company Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

City {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Transaction Value {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Telephone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Fax Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

3. Bank Reference

Bank Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

City {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Province/State {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Postal Code/Zip Code {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Country {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Contact Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Telephone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

4. Invoicing Preferences

Upload Invoicing Preferences Document {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

How Would You Like Your Invoices Submitted? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Name of Electronic Submission System {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email Address to Submit Invoices {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Mailing Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

City {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Province/State {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Country {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

5. Invoicing Requirements

What Information Must Invoices Include? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Currency to be Invoiced {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

6. Names of Key Executive Officers & Directors

Executive Officer & Director Information Document {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Please List Your Executive Officers & Directors

Name

Title

Telephone Number

City

Name {binding ItemNumber}

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Title {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Telephone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

City {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

7. Financial Status

If you will be proving, please attach your most recent financial statements {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Main bank name and address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Auditor company name and address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

List your top THREE major creditors {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Average payment history on outstanding invoices {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

DISCLAIMER

The above information is warranted to be true and is given for the purpose of obtaining credit. In the event credit is granted, I/we agree to abide by your terms of sale-net 30 days. I/we agree to pay interest charges at the rate of 18% per annum on overdue accounts.

Disclaimer Acceptance

Completed By {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Title {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Telephone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}