COMPANY NAME: STREET: CITY: POSTAL CODE:  PHONE:  FAX:  EMAIL:  PREVIOUS ADDRESS (IF LESS THAN TWO YEARS) STREET: CITY: POSTAL CODE:  TYPE OF BUSINESS: HOW LONG IN BUSINESS:

BANKING INFORMATION

BANK NAME STREET CITY POSTAL CODE CONTACT NAME PHONE

CREDIT REFERENCES

Name: Address: Phone: Fax: 1. 2. 3.

I HEREBY AUTHORIZE COM-PLEX SYSTEMS LTD CO TO VERIFY ANY OF THE ABOVE INFORMATION FOR THE PURPOSE OF ESTABLISHING MY CREDIT APPLICATION.