PERSONAL CREDIT APPLICATION

CREDIT APPLICATION

PO BOX 2591, LA CRETE AB, TOH-2HO ┃ 780-928-5067 OFFICE@PLATINUMFUELS.CA
For this form you will need your drivers license and a direct deposit form or void cheque.
NAME

First NameLast Name
FUEL CREDIT NEEDED PER MONTH:
Write an amount between $200 - $1,500
PHONE NUMBER
Please enter a valid phone number.
SECONDARY PHONE NUMBER
(Optional)
EMAIL ADDRESS
example@example.com
ADDRESS

Box Number

Street Address Line 2

City/ TownProvince

Postal Code
DRIVERS LICENCE #
DATE OF BIRTH

MonthDayYear
Date
REFERENCES
BANK
BRANCH
I/We Name Name apply for a credit for the supply of goods, services and materials in accordance with the application for credit concurrently
made. I/we being principals(s) of the company acknowledge that I/we am/are co-customer(s .co-purchasers and will be personally responsible jointly and serially with the company for any and all debts. I/we will jointly and severally indemnify you, and see you paid for your account with respect to any order now or hereafter made by the company I/we further agree to pay your account withing your terms of payment 30 days following purchase, to pay 2% interest per month (26.83 per annum) on overdue accounts and I/we assure full responsibility for any costs incurred toward collection of account including legal fees. For the purpose of this credit transaction, I/we fully consent and authorize yourselves obtaining any personal credit information of the principal(s) or the company through any credit bureau, credit reporting agency government registry, private registry, or civil enforcement agency. Dated at: dd/mm/yyyy in the province Provincethis This day Day 20Year
PRINT NAME
SIGN NAME

Clear
Should be Empty:

CREDIT APPLICATION

REFERENCES