Personal Credit Application Form - Western Petroleum

PERSONAL CREDIT APPLICATION FORM
General Information:
Name:
Address:
City /Town: Postal Code:
Telephone #: Fax #:
Work #: Cell / Other:
E-Mail Address(s):
Employer: Years Employed:
SIN: Drivers License #:
Date of Birth: Marital Status:
Bank Name / Location: Contact at Bank:
Spouse Name: Spouse Employer:
How Long at Present Address: Tenant Owner
Credit Limit Requested:
Delivery Service Information
Delivery Remarks:
Product (s) Required:
Tank Location: Inside Outside Tank Certified: Yes No
Age of Tank: Delivery Type: Call Auto
Automatic Visa Payment: Yes No Budget Plan: Yes No
Payment Method: Cash Cheque Visa Online / Telephone
Signature:
Name (Please Print):
Date:
Office Use Only
Credit Limit Approved:
Approved By :
Date:
I hereby apply to Western Petroleum for a credit account and certify that the information shown here is
true and that the information given is for the purpose of obtaining goods on credit. I hereby authorize the
person or firm to who this application is made, any credit bureau or other investigation agency employed
by such person, to investigate the references herein listed or to receive or give credit information on any
other data obtained from me, or from any other person pertaining to my credit or financial responsibility.
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