Company Information Company Business Phone Address   Business Fax City   Type of Business Province   Manager Postal Code   Years Established Owner(s)   Credit Required Permit #   Email       Web Site           Trade References Name       Address       Phone Number   Fax Number           Name       Address       Phone Number   Fax Number           Name       Address       Phone Number   Fax Number           Bank Reference Bank   Phone Number Address       Contact   Account Number           I/We agree to pay within the specified terms (Net 30 days) and realize that the extension of credit may be canceled at any time at the discretion of National Shoe Specialties Limited. *$20.00 will be charged to all N.S.F. cheques and a 2% monthly service fee will be charged to all overdue accounts.           Name   Date