Fillable Printable Personal Credit Application Form - Western Petroleum

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.