Haliburton Tim-Br Mart
(705) 457-2510 or (877) 425-5862

Account Application Form

Personal Information
First Name:
*
 
Last Name:
*
 
Date of Birth (MM/DD/YYYY):
*
 
Drivers License:
*
 
Home Phone #:
*
 
Business Phone #:
 
Cell Phone #:
 
Email Address:
*
 
Receive your statement and invoices by email?
*
    Yes:   No:
 
Billing Information
Address:
*
 
City:
*
 
Province:
*
 
Postal Code:
*
 
Credit Card Type:
*
 
Credit Card #:
*
 
Expiry:
*
 
Airmiles #:
 

I consent to charges on my credit cards if payment is past
due or exceeds the approved amount:
I Accept:
*
 
Shipping Information
House / 911 #:
 
Street:
 
City:
 
Work Site Phone #:
 
Additional Shipping Information:
Financial Information
Financial Institution:
 
Bank Branch:
 
Bank Phone #:
 
Currently Employed at:
 
Business Reference:
 
Amount of Credit Applying For:
 
The Applicant consents to the obtaining of credit or personal information required at any time. Payment is due in full by the 15th of the month following. The Applicant agrees to pay interest on any outstanding balance at the rate of 2% per month. On default the Applicant further agrees that all lawyers fees and or agents costs of recovering the debt are also payable.
I Accept:
*
 
All fields marked with an (
*
) are required.

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