ONLINE CREDIT APPLICATION
Date Form Completed
Company Name
Contact Name Re: Purchasing
Contact Name Re: Payables
Mailing Address
Shipping Address
Phone
Fax
E-Mail
Requested Credit Limit		per month
Name, Address & Fax# of Bank and Branch		Name Address Fax# Branch
Name, Address & Fax# of 3 Largest Suppliers	1	Name Address Fax#
	2	Name Address Fax#
	3	Name Address Fax#
Signature of Completor
Title
PLEASE PRINT OUT APPLICATION AND FAX TO AUSCAN MELALEUCA LTD. AT 519-893-4384.  We will advise results of credit investigation once it has been completed.  Thank you for your co-operation.