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Credit Application

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Fill out and Submit the following form to apply for an All-Glass Parts Charge Account. You may also download and fax the application. Please read our Terms and Conditions prior to filling out an application.

Download the Credit Application in PDF
Optionally fax applications to: Toll-Free: 1-877-484-1209 (Canada & USA)


Company Name:
Applicants Name:

Billing Information
Billing Address:
City:
Province / State:
Postal Code / Zip:

Contact Information
Phone Number:
Fax Number:
Email Address:

Business Information
Type of Business:
How long has your business been in operation?
Type of Account:	Charge Account Credit Card Cash / Cheque

Shipping Information
Shipping Address:
City:
Province / State:
Postal Code / Zip:

Purchaser Name:
Purchaser Email:
Accounts Payable Contact:
Is Business a:	Corporation Partnership Sole Proprietorship
F.S.T Number:	(OPTIONAL)
P.S.T Number	(OPTIONAL)

Bank Information
Bank Name:
Bank Phone #:

Principals
1. Name:
1. Phone Number:
2. Name:
2. Phone Number:
3. Name:
3. Phone Number:

Trade References
A. Company Name
A. Phone Number:
A. Fax Number:
B. Company Name
B. Phone Number:
B. Fax Number:
C. Company Name
C. Phone Number:
C. Fax Number:

I Agree, to the Terms and Conditions