Customer 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

For Contract Coordinator Use Only







Type of application New customer account
Amend customer account



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. 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 PSU 932 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.

Corporate/Individual Information


Head Office Address













Billing / Delivery Address (if different from above)








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

Taxability: Indicate exemption numbers when applicable

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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:

Credit Conditions

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. 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.
  4. 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.
  5. The customer shall notify the Minister of any change of address or ownership within five working days from the date of those changes.
  6. 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.


Alternative Formats

Help with Alternative Formats

Customer Application (On-Screen Fillable PDF version, 64.3 KB)

Date modified: