New Customer Account Info

Become a verified customer with Verduyn for benefits like purchase history and service lookup.

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

Business Information

Legal Business Name*

Business Trade Name(s)

(if applicable)

Type of Business

Sole Proprietor

Partnership

Corporation

Individual

Primary Business Phone*

Primary Business Email*

Business Mailing Address*

Street Address Address Line 2 City Province / State Postal Code / ZIP Country

Business Shipping Address (if different from Billing Address)

Business Shipping Address

Street Address Address Line 2 City Province / State Postal Code / ZIP Country

Shipping Address

Primary Contact

Primary Contact Name*

First Last

Primary Contact Phone

(if different from Primary Business Phone)

Primary Contact Email

(if different from Primary Business Email)

PO Numbers Required?*

Yes

P.O. Contact

P.O. Contact Name*

First Last

P.O. Phone*

P.O. Email*

Purchasing Contact (optional)

Purchasing Contact Name

First Last

Purchasing Contact Phone

Purchasing Email

Purchasing Contact (optional)

Accounts Payable Contact (optional)

Accounts Payable Contact Name

First Last

Accounts Payable Phone

Accounts Payable Email

Accounts Payable Contact (optional)

Additional Info

HST/GST Reg. #:

Do You Have a Canadian Tax Exemption?

If yes, we will contact you for further details.

Yes, I have a tax exemption.

Would you like to apply for credit terms?

Yes, please contact me about credit terms for my account.

Would you like to join our mailing list to receive exclusive discounts and promos?

Yes, I want exclusive offers and event info.