P.O.BOX 11490, STATION "H"
3701 CARLING AVE. BLDG. 94
OTTAWA, ON K2H 8S2
TELEPHONE : (613) 990-4389
FAX. NO. :(613) 990-5009
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YOUR P.O. / FILE NUMBER:_________________ |
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COMPANY'S NAME:
CONTACT PERSON:
TELEPHONE NUMBER:
FAX NUMBER:
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ADDRESS: |
CREDIT CARD AUTHORIZATION
NAME OF CARD:
(VISA/MASTERCARD)
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CARD NUMBER: |
CARDHOLDER'S NAME:
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EXPIRATION DATE: |
AMOUNT AUTHORIZED : _________________________________CANADIAN FUNDS
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CARDHOLDER'S SIGNATURE : ____________________________ |
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I agree to pay above total amount according
to card issuer agreement.
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CERTIFICATION REQUESTED
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APPLICANT'S NAME:
ADDRESS:
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TRADE NAME:
TYPE OF MODEL:
CERTIFIED UNDER:
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QUANTITY
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COST
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(NOTES IF ANY) |
| LABEL FEES |
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| ASSESSMENT FEEES |
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| **CERTIFICATE FEES |
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** GST NOT APPLICABLE |
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PST
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PST APPLICABLE ONLY IN QUEBEC |
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GST
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GST APPLICABLE ONLY IN CANADA |
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TOTAL
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