Open An Account

 

    Company Information
    1. Name of your representative :
    2. Company Name :
    3. Type of business :
    4. Number of years in business :
    5. Address :
    6. City :
    7. Province :
    8. Postal code :
    9. Phone number :
    Responsible for shipping
    1. Name of your representative :
    2. Email :
    3. Username for Priodex online account :
    4. Password for Priodex online account :
    Payment information
    1. Card type :
    2. Name of the card holder :
    3. Card number :
    4. Expiration date (mm / yy) :
    5. CVV number :

      Or by Interac-transfer to payable@priodex.com

    Credit reference (s)
    1. Company :
    2. Contact(s) :
    3. Phone number :
    Name Account Manager
    1. Last and first name