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General Information
Operating Name
*
Legal Business Name
*
Business Registration Number
*
Website
*
What type of business do you have?
Regional Retailer
Wholesaler
National Retailer
Independent Retailer
Online Retailer
Residential Design / Decorating
Other (please specify):
Billing Address
Address (Line 1)
*
Address (Line 2)
City
*
Province
*
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Northwest Territories
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Postal Code
*
Country
*
Canada
USA
Telephone
*
Fax
Contact Name
*
Email
*
GST / HST Account #
*
Shipping Address
Shipping Info same as of Billing's
We do not ship to residential addresses
Company Name
*
Address (Line 1)
*
Address (Line 2)
City
*
Province
*
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Northwest Territories
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Postal Code
*
Country
*
Canada
USA
Telephone
*
Fax
Contact Name
*
Email
*
Always ship to unless otherwise instructed
Preferred Method Of Payment
Credit Card
Certified Cheque
Wire Transfer
Buying Group Affiliate
Mega Group Inc.
Cantrex Nationwide
Alliance International
Mega Group Inc.
Account #
Auto Approval
Yes
No
Cantrex Nationwide
Account #
Auto Approval
Yes
No
Alliance International
Account #
Auto Approval
Yes
No
Contacts
(If different than Billing's)
Buyer
Name
*
Job Title
Email Address
*
Telephone
Ext.
Fax
Owner / President
Name
*
Job Title
Email Address
*
Telephone
Ext.
Fax
Order Confirmations
Name
*
Job Title
Email Address
*
Telephone
Ext.
Fax
Catalogue Updates
Name
*
Job Title
Email Address
*
Telephone
Ext.
Fax
Shipping Notifications
Name
*
Job Title
Email Address
*
Telephone
Ext.
Fax
Invoice Notification
Name
*
Job Title
Email Address
*
Telephone
Ext.
Fax
*
I have read, understand and agree to the above policies and procedures of Midas Accents Inc.. Please also visit our General Info on our website at
www.midasaccents.ca
for full details and updates on our policies and procedures, and our company offerings.
Applicant's Name
*
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