Central Courier Services Ltd.

Business Office
9182 34a Ave NW Edmonton, AB T6E 5P4
Mon - Sat
9:00 am - 6:00 pm

Customer Registration Form

Note: To receive services from Central Courier Services, you must be registered with us either as an individual customer or as a registered business (corporate client). All customers are required to complete the information below. Incomplete or incorrect information may result in delays in service.

Completed forms must be emailed to dispatch@centralcourier.ca along with a void cheque.

Request Type * New Customer Existing Customer

1. CUSTOMER INFORMATION
Company Name	Customer Legal Name:* Business Corporate Number:* Doing Business As: {if different than above} Email:* * Phone No Valid Invalid number

Address

Business Address

Street:*

City:*

Province/State:

Postal Code/Zip:

Country:

Account Payable Contact

Name:

Title:

Telephone: Ext: Fax: Email:

2. Payment Information
Electronic Payment Information (Please provide a voided cheque along with the completed form)	CANADIAN DOMICILED BANK ACCOUNT Bank Name: Bank Address: Bank Institution #: Bank Transit #: Bank Account #: Full Name on Account: Swift # (Wire): Currency (CAD, USD)

3. Tax Information
Tax Declaration	GST # HST # QST # If exempt, please explain why:

4. Payment Terms
Payment Terms	The customer shall pay the invoice no later than thirty (30) days from the date of invoice, unless otherwise agreed. For customers on a delivery basis, payment is due upon delivery.

5. Certification
By checking the box and signing this form, you confirm that the information provided above is complete and accurate, and that you are an authorized signatory on behalf of the company. You also authorize Central Courier Services to initiate direct deposits to the bank account specified in this document. This authorization will remain in effect until we receive written notice of cancellation. Please notify us promptly if you close or modify your banking arrangements. Name: Title/Position: Date:

Other Information
Driving License/Photo ID: Driving License/Photo ID Copy:* Expected Average Shipments / Month* Product Type * Select Nature of Account * Password * Confirm Password *

Office Info

780-752-0248
admin@centralcourier.ca
9182 34a Ave NW Edmonton, AB T6E 5P4

Business Office

Mon - Sat

Customer Registration Form

Business Address

CANADIAN DOMICILED BANK ACCOUNT

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