Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Shipping Address (if different than mailing address)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone number *

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Fax Number

(###)

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Company Industry *

Electrical Contractor

Agriculture

Electrical Dealer

Manufacturing

Oil and Gas / Compresser

Concrete and/or Aggregate

Fab / Welding Shop

HVAC

General Contractor

Government

Property Management

Other

Principal Owners / Contacts (including Accounts Payable contact)

First Contact

First Name

Last Name

Phone

(###)

###

####

Contact 2

First Name

Last Name

Phone

(###)

###

####

Contact 3

First Name

Last Name

Phone

(###)

###

####

Contact 4

First Name

Last Name

Phone

(###)

###

####

Contact 5

First Name

Last Name

Phone

(###)

###

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Trade References

To avoid delays in approving your credit application, please be sure the companies you list as trade references will provide your account history to us. Please do not use Westburn Electric Supply, Eecol Electric, Guillevin or Wolseley Canada as they do not provide account history to third parties and will result in delays approving your trade account with Civic Recycling.

I understand

Phone

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Phone

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Phone

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