● 600 THIRD STREET ● LONDON, ONTARIO ● N5V 2C2 ●

CUSTOMER INFORMATION

CONFIDENTIAL CREDIT APPLICATION

Trade Name: __________________________________________________________________________

Company Address: ____________________________________________________________________

City: ______________________ Province: ____________ Postal Code: _______________________

Incorporated Name (If Different From Trade Name): ____________________________________________

Telephone #: __________________________ Fax #:________________________________________

Provincial Sales Tax #: ________________________ GST Registration #: ________________________

Type of Business: _________________ Year Started: __________ Proprietorship, Partnership, Corporation

Accounting Contact Name: __________________________ Phone #: __________________________

EMAIL ADDRESS FOR BUYER ______________________________________________________________________________

Name of Principal (Owner): _____________________________ SIN #: ___________________________

Home Address: __________________________________ Phone #: _________________________

City: ______________________ Province: _______________ Postal Code: ____________________

How long have you owned this business? ________________ Previous business: ___________________
*******************PLEASE ATTACH A PHOTOCOPY OF YOUR DRIVER’S LICENSE**************************

Name of Principal (Owner): _____________________________ SIN #: ___________________________

Home Address: __________________________________ Phone #: _________________________

City: ______________________ Province: _______________ Postal Code: ____________________

How long have you owned this business? ________________ Previous business: ___________________

Bank Name: _______________________________ Branch Address: _________________________

City: ____________________ Account #: _____________________ Contact Name: ________________

Principal Supplier Address City Telephone #:

1. _____________________________________________________________________________

2. _____________________________________________________________________________

3. _____________________________________________________________________________

I/We the undersigned are making application for a charge account with Courtney Wholesale Confectionery Limited (“Courtney’s”). The undersigned agree(s) to be bound by the terms of sale which are described on the invoice. I/We the undersigned further accept and agree that interest shall be charged, at the rate of 1 ½ % per month (18% per annum), on all amounts owed which are more than 30 days past due; further, a service change of not less than $20.00 shall be assessed against each and every cheque that is returned NSF from our bank. I/We the undersigned accept and agree that title to all goods delivered or otherwise provided under this agreement, shall remain with Courtney’s, until such time as said goods have been paid for in full,, to the satisfaction of Courtney’s. The undersigned hereby authorize(s) Courtney’s to make inquiries, obtain credit and other information, and to use credit reporting agencies in its consideration of this credit application. The undersigned further authorize(s) Courtney’s to share credit information with credit reporting agencies, as Courtney’s deems appropriate.

Signature: ________________________ Title: ____________ Date: __________________

Signature: ________________________ Title: ____________ Date: __________________

SALES REP USE ONLY OFFICE USE ONLY

DELIVERY DAY: _________________ DATE: ________________

SALES DAY: _________________ CUSTOMER #: ________________

CUSTOMER TYPE: _________________ SIGNATURE: ________________

SALES REP #: _________________ ROUTE #: ________________

TERMS REQUESTED: _________________ TERMS GIVEN: ________________

Courtney Wholesale Confectionery Limited

PAYOR’S AUTHORIZATION FORM FOR PRE-AUTHORIZED DEBIT (“PAD”)

Instructions: Please complete all sections to instruct your financial institution to make payments directly from your account.

Return the completed form with a blank cheque marked “VOID” to the Payee below.

PAYOR INFORMATION (Please type or print clearly)

Payor Name(s):
Address:
Telephone:	Fax:
Email Address:

PAYOR FINANCIAL INSTITUTION/BANKING INFORMATION

Institution Number:	Branch Number:		Account Number:
Name of Financial Institution:
Branch:
Branch Address:
City/Postal Code:		Province:
Telephone:		Fax:

PAYEE INFORMATION

Courtney Wholesale Confectionery Limited

600 Third Street

London, Ontario

N5V 2C2

Phone # (519) 451-7440 Fax # (519) 451-9792

courtneys@execulink.com

This form is for Business Pre-Authorized Debit Plans which relate to commercial activities of a Payor who is a corporation, organization, trade, association, government entity, profession, venture, partnership, sole proprietor or enterprise.

1. We warrant and guarantee that the above information is accurate.
2. We undertake to inform the Payee, in writing, of any change in the information provided in this Authorization prior to the next due date of the PAD.

3. We acknowledge that this Authorization is provided for the benefit of Payee and the Financial Institution and is provided in consideration of the Financial Institution agreeing to process debits against the account as listed above the “Account” for business purposes in accordance with the Rules of the Canadian Payments Association.

4. We warrant and guarantee that persons whose signatures are authorized to sign on the Account have signed this Authorization and that the persons signing this Authorization are our Authorized signing officers and are empowered to enter into this agreement.

5. The Account that the Payee is authorized to draw upon is indicated above. A specimen cheque available for this Account has been marked “VOID” and is attached to this Authorization

6. We hereby authorize Payee to issue PAD’s (as defined in Rule H1 of the Rules of the Canadian Payments Association) drawn on the Account for GOODS SOLD, INVOICED and DELIVERED.

7. We hereby authorize Payee to issue PAD in a variable dollar amount up to maximum of $_________ (subject to any further adjustments), at set intervals as agreed from time to time between the parties.

8. Unless otherwise agreed to in writing, we acknowledge and agree that Payee will provide to us, at the address provided in this Agreement:

1. with respect to fixed amount PADs, written notice of the amount to be debited (the “Payment Amount”) and the date(s) on which the Payment Amount debited will be posted to our Account (the “Payment Date”), at least 2 calendar days before the Payment Date of the first PAD, and such notice shall be provided every time there is a change in the Payment Amount or the Payment Date(s);

2. with respect to variable amount PADs, including any representment or reprocessing of PADs which were returned for the reason of Non-Sufficient Funds or Funds Not Cleared, written notice of the Payment Amount and the Payment Date(s), at least 2 calendar days before the Payment Date of every PAD;

3. with respect to variable amount PADs, including any representment or reprocessing of PADs which were returned for the reason of Non-Sufficient Funds or Funds Not Cleared, where the option chosen is 0 days, written notice of the Payment Amount and the Payment Date must be received by the Payor no later than 14:00 EST on the same day, or in the event of force majeure or any event reasonably beyond the control of the Payee, written or verbal notice of the Payment Amount and the Payment Date must be received by the Payor no later than 15:30 EST on the same day; and

4. with respect to a PAD plan that provides for the issuance of a PAD in response to a direct action of ours (such as, but not limited to, a telephone instruction) requesting Payee to issue a PAD in full or partial payment of a billing received by us for a payment obligation that meets the requirements of SECTION 14 of Rule H1, no notice is required.

All Payment Amounts must exactly match the amount specified in the written notice for the specified Payment Date.

9. We may dispute a PAD only under the following conditions:

a) The PAD was not drawn in accordance with the Authorization; or

b) The Authorization was revoked; or

c) Pre-notification, as required under SECTION 8 was not received.

We acknowledge that in order to be reimbursed, a declaration to the effect that either (a), (b) or (c) took place, must be completed and presented to the branch of the Financial Institution holding the Account up to and including 10 business days after the date on which the PAD in dispute was posted to the Account, Payee will also be advised simultaneously.

We acknowledge that when disputing any PAD beyond the time allowed in this section, it is a matter to be resolved solely between Payee and Payor outside the payment system

10. We acknowledge that the Processing Institution is not required to verify that a PAD has been issued in accordance with the particulars of the Authorization including, but not limited to, a) the amount or b) that any purpose of payment for which the PAD was issued has been fulfilled by Payee as a condition to honouring a PAD issued or caused to be issued by Payee on the Account.

11. We acknowledge that revocation of this Authorization does not terminate any contract for goods or services that exists between Payee and Payor. The Authorization applies only to the method of payment and does not otherwise have any bearing on the contract for goods or services exchanged, which remains in full force and effect.

12. This authorization may be cancelled by either the Payor and the Payee at any time upon providing written notification to the other party. Such cancellation will be effective immediately upon receipt of notice by both parties.

13. We acknowledge that provision and delivery of this Authorization to Payee constitutes delivery by us to the Financial Institution. Any delivery of this Authorization to Payee regardless of the method of delivery, constitutes delivery by us.

14. We agree that the information contained in this Authorization may be disclosed to the Payee’s Financial Institution as required to complete any PAD transaction.

15. We understand and accept the terms and conditions of participating in the PAD plan.

Company Name:	Date:
Authorized Signature:	Print Name:
Authorized Signature:	Print Name: