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Identification

Merchant Banner

Central Billing

Merchant Number

Legal Name of the store *

Email

Address (#civic, street and 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 Address

Owner Cell Phone Number 2

Credit Reference

Company

Phone Number

Contact Name

1. 

2. 

3. 

Main Financial Institution

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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