*Mandatory Fields
Merchant Banner
Central Billing
Merchant Number
Legal Name of the store *
Email
Address *
City *
Phone Number *
Fax Number
Country
Province / State ALBERTA BRITISH COLUMBIA MANITOBA NEW BRUNSWICK NEWFOUNDLAND NOVA SCOTIA ONTARIO PRINCE EDOUARD ISLAN QUÉBEC SASKATCHEWAN YUKON
Postal Code *
Tobacco License Number
Federal / HST Tax Number *
Provincial tax #
Owner Name 1 *
Owner Home Phone Number 1
Owner Address
Owner Cell Phone Number 1
Owner Name 2
Owner Home Phone Number 2
Owner Cell Phone Number 2
Company
Phone Number
Contact Name
1.
2.
3.
COD
Credit Card
Bank Name
Bank Address
Bank Phone Number
Bank Account Number
Bank Transit Number
According to article 37 of the Civil Code of Quebec, I hereby authorize Casa Cubana / Spike Marks Inc.. and / or any credit reporting agency and / or bank with which I deal, to obtain and disclose all relevant information to our credit. I agree that any products supplied by Casa Cubana remains the property of Casa Cubana until the 'complete and total payment of this commodity. Thus, any amount unpaid its due date will result in the automatic loss of the benefit of any term of payment that could have been provided by Casa Cubana to its customer.
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