Credit Application

You can use either the Web version or another version of the form from the Alternative Formats section.

Please complete, print and send the form by mail.

Please mail to:

Saint-Hyacinthe Research and Development Centre
Agriculture and Agri-Food Canada
3600 Casavant Boulevard West
Saint-Hyacinthe, Quebec
J2S 8E3

Protected once completed

(When the Credit Application form AAFC / AAC5119 is completed, form AAFC/ AAC5132 Customer Application is not required)

For Contract Coordinator Use Only







Type of application First credit application
Increase credit limit
Reinstatement of credit
 




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Part A - Corporate/Individual Information


Head office address













Billing / Delivery address (if different from above)








Form of business organization  Business Corporation (Provincial)
 Partnership
 Cooperative
 Charity/Trust (attach details of funding)
 Business Corporation (Federal)
 Limited partnership
 Sole proprietorship
  
  
  

Taxability: Indicate exemption numbers when applicable

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Ownership Canadian
Foreign


If you purchase goods or services on credit from other government departments

(Please provide information on your credit status)











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Part B - Additional Information for Credit Assessment



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Principal Owners

(Use separate sheet if required)







































































Bank

(If a proprietorship or partnership, please provide financial institution information for each of the owner(s) partners)




































Main Suppliers

Please list your main suppliers (At least two who extend credit terms to your company)








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Part C - Authorization and Privacy Notice

Authorization and Privacy Notice by the individual(s) recognized as the signing authority(s) at the client's financial institution

I certify that the above information is correct and hereby apply for credit privileges from Her Majesty the Queen in right of Canada as represented by the Minister of Agriculture and Agri-Food, hereinafter referred to as "Her Majesty". The application referred to in PartӬA and if applicable, the owner of a proprietorship or partners in a partnership referred to in PartӬB, by the authorized signature(s) below, consents to the receipt and exchange of credit information by Her Majesty with any credit reporting agency, credit bureau, financial institution or any person or corporation with whom the client has or proposes to have financial dealings. I have read the credit conditions on the back of this application and, if credit is granted to the applicant, the applicant agrees to abide by those conditions.

The information you provide on this document is collected by Agriculture and Agri-Food Canada (AAFC) under the authority of the Financial Administration Act (FAA), the Income Tax Act (ITA) and the Farm Income Protection Act (FIPA) for the purpose of supporting the collection of monies owing to the institution/ Receiver General for Canada. The information will be used to evaluate the financial viability of the individual or the company, to obtain financial information from credit agencies / financial institutions / suppliers. The information may be shared with collection agencies for debt recovery purposes. The personal information will be protected under the provisions of the Privacy Act and is described in Personal Information Bank PSUӬ932 entitled "Accounts Receivable". You have a right to access your personal information and request changes to incorrect information should you wish to avail yourself of this right, please contact the ATIP Coordinator at 613-773-1386.

The conditions governing credit privileges provided by the Minister are: "Minister" means the Minister of Agriculture and Agri-Food or anyone authorized to act on the Minister's behalf. "Customer" means an organization or an individual that has an account with Agriculture and Agri-Food Canada.

  1. The customer shall pay Her Majesty for the amount of all goods or services received subject to terms of payment in effect on the date of the provision of the goods and services and as stated on an invoice or other written document specifically applicable to such provision which shall be provided by the Minister. Discounts will not be granted for prompt payment. Customer will be charged interest on any overdue amounts in accordance with agreements or as permitted by legislation/regulation.
  2. An administrative fee will be applied to any account whose cheque or other payment instrument is not honoured by the financial institution on which it is drawn, for reasons of Non Sufficient Funds ("NSF") or otherwise.
  3. Based on the results of the credit evaluation and when contractual agreement permits, a security deposit may be requested from the customer by the Minister whenever the customer's future ability to discharge a debt in accordance with the payment terms is uncertain; or the customer has a history of late payment accounts.
  4. Credit privileges may be withdrawn or the terms of payment may be revised if it is discovered that the customer has made a material false declaration or is otherwise in breach of imposed terms and conditions; or, the customer's credit limit has been reached and a reassessment of the account does not support increasing the credit limit; the Minister obtains evidence that the customer's financial viability is doubtful and/or there is no reasonable expectation of receiving payment for services requested or any other reason deemed appropriate by the Minister. When credit privileges are withdrawn, the customer shall pay in advance for any required goods and services.
  5. If as a result of false information, a customer obtained credit which would not have otherwise been given, full payment by the customer shall be made immediately, regardless of any decisions regarding possible prosecution of the customer.
  6. Upon receipt of a request from departmental officials, the customer shall provide a copy of the company's financial statements or any other documents requested.
  7. The customer shall notify the Minister of any change of address or ownership within five working days from the date of those changes.
  8. Any information that is provided in this application, or in contacts with departmental officials relating to the granting of credit under this application, may be used by the Government of Canada or its agents, consistent with accepted commercial practices, and pertinent federal and provincial statutes and policy directives, to collect accounts. The collection of overdue amounts may involve the use of Private Collection Agencies and the provision to them of information provided by the customer.
  9. For the collection of an overdue account, be advised that if you are eligible for a payment from Agriculture and Agri-Food Canada, Canada Revenue Agency or any other department or Agency of the Crown, we may take action to have such payment held and applied against your outstanding debt and that information provided by the customer may be provided to another government department.



Signature:





Signature:



Finance Unit

Please forward the completed Credit Application to the Finance unit:









For Finance Unit Use Only

AAFC Local Finance officer signature:

Date:

Finance unit to forward the completed Credit Application to Revenue Management section:

Telephone number: 1-800-282-6249

Fax number: 1-613-773-0660

For Revenue Management Section Use Only

Customer number:

Signature:

Date:

  • Approved $
  • Approved with condition(s) $
  • Decline

Recommended by:

Date:

Approved or declined by:

Date:

Please make sure that the Authorization section Part C is signed.


Alternative Formats

Help with Alternative Formats

Application Form (On-Screen Fillable PDF version, 890 KB)

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