Nomad Fuel Application Form

Legal Business Name*
Trade Name
Street Address*
Unit / Suite*
City*
Province*
Postal Code*
Phone Number*
Billing Email Address*
example@example.com

HST Number*
Number of Trucks*
MC Number
US DOT Number (if applicable)

Website
Additional
Monthly Sales Volume
Current Bank
Current Fuel Provider (if applicable)
Current Factor (if applicable)

Ownership
Owner Full Name (1)*
Percentage Owned*
Driver’s License Number*
SIN*
Home Address
Cell Number

Owner 2

Fill this out if applicable
Owner Full Name (2)
Percentage Owned
Driver’s License Number
SIN
Home Address
Cell Number

Estimated Usage
Estimated Monthly Fuel Volume – Liters
Estimated Monthly Fuel Volume – $CDN
Estimated Monthly Fuel Volume - Gallons
Pre Authorized Debit Frequency:*

DailyTwice WeeklyWeekly
Monthly Fuel Volume - $USD
Number of Cards Requested*

Signatures
The undersigned certifies the above information to be true and correct. The undersigned hereby authorizes Nomad Fuel Inc. ("Lender”) and/or any of its designated underwriters, or an authorized Agent, to obtain, or exchange personal information in whatever manner it may deem satisfactory, all the credit information it requires, whatever the source, such source(s) being hereby authorized to provide such information.
CONSENT TO PERSONAL INFORMATION SHARING
By signing below, Applicant consents and authorizes Lender and its agents, at any time to communicate with and disclose to third parties (including Credit Reporting Agencies, Credit Exchanges, Leasing Brokers and Credit Grantors) any of Applicant’s credit, financial and personal information that Lender deems necessary to complete, service or enforce this Application and any Ancillary Agreements, including additions, modifications, updates or other related transactions, including but not limited to the Factoring Facility. This clause survives the term or termination of this Application.
CREDIT INVESTIGATION
Applicant hereby authorizes Lender to conduct financial and credit investigations of Applicant for the purposes of approval, maintenance and enforcement of this Facility, or any judgment obtained by Lender as a result of any default hereunder, and to obtain any information required from any source to which it may apply, and each source is hereby authorized to provide such information to Lender. This includes, but is not limited to, Lender obtaining information from any credit reporting agency, creditor of Applicant, or banking and other financial institution where Applicant may have credit or depository facilities. Lender may obtain such information at any time before or during the Facility Term or after termination of the Facility in the event any monies remain owing to Lender.

If you are an applicant or co-applicant you must each sign this credit application below:
Authorized Signature*

Clear
Print Name*
Date*

MonthDayYear
Date
Co-Applicant Authorized Signature (if applicable)

Clear
Co-Applicant Print Name
Co-Applicant Signature Date

MonthDayYear
Date

Documents
ID Of Directors (2 pieces each)

Cancelof
3 Months Bank Statements (most recent)

Cancelof
Void Cheque

Cancelof

Should be Empty:

Additional

Ownership

Owner 2

Estimated Usage

Signatures

CONSENT TO PERSONAL INFORMATION SHARING

CREDIT INVESTIGATION

Documents