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Credit Application

Please complete this application and click on the Submit button below. To download and print a PDF Copy of our Credit Application form, click here. Please be sure to include Area Codes for all Phone and Fax numbers.

Company Information
Company Name
Company Addr.
City
Prov/State
Post/Zip Code
Phone Number
Fax Number
Contact Name
Contact Title
E-Mail Address
Website Address
Bus. Start Date
Incorp. Date
# of Employees
Type of Business
# Yrs. in Bus.
Bus. Structure
Bus. Premises Owned Leased Other
Landlord / Mtg. Holder
Contact Name
Phone Number
Fax Number

Principal Details
Name
Position with Co.
% of Ownership
Home Address
City
Prov/State
Postal/Zip Code
Phone Number
Birthdate M/D/Y
S.I.N. / S.S.N.
Residence Owned Rented Other
Mtg./Rent Pmt.
Home Value
Mtg. Balance
Marital Status

Bank Information
Bank Name
Branch Name/#
Branch Address
Account Number
Phone Number
Fax Number
Contact Name
Years Dealing

Trade References
Reference One
Phone Number
Fax Number
Reference Two
Phone Number
Fax Number
Reference Three
Phone Number
Fax Number

Equipment Information
Equip. Descrip.
Equip. Condition New Used Reconditioned
Pretax Cost
Currency US Dollars Canadian Dollars
Supplier Name
Sales Person
Phone Number
Fax Number
Term Requested

THE UNDERSIGNED CERTIFIES THE ABOVE INFORMATION TO BE TRUE AND CORRECT. I/WE HEREBY AUTHORIZE WESTPORT LEASING CORPORATION AND/OR ITS THIRD-PARTY AGENTS, OR ASSIGNS (WESTPORT) TO COLLECT, RETAIN, USE, DISCLOSE & EXCHANGE CREDIT REPORTS, BANKING & CREDIT REFERENCES, AND OTHER PERSONAL INFORMATION FOR ALL PURPOSES RELATED TO CONFIRMING IDENTITIES, THE EVALUATION OF CREDIT WORTHINESS, PROVIDING LEASING AND/OR OTHER FINANCIAL SERVICES, ADMINISTERING CONTRACTS, REGISTERING SECURITY INTERESTS, PERFORMING INTERNAL STATISTICAL ANALYSIS, REPORTING ACCOUNT INFORMATION TO CREDIT AGENCIES AND OTHER CREDITORS, AND/OR OTHER PURPOSES AS REQUIRED OR PERMITTED BY LAW. I/WE ACKNOWLEDGE THAT FILES CONTAINING MY/OUR PERSONAL INFORMATION MAY BE KEPT AT WESTPORT'S OFFICES AND THAT I/WE HAVE A GENERAL RIGHT TO ACCESS AND RECTIFY PERSONAL INFORMATION IN THE FILES BY SUBMITTING A WRITTEN REQUEST TO WESTPORT.

If this form is being faxed, send to (604) 681-1260 or 1 (800) 667-0747
Please sign and date on the line below.


X______________________________________________________    Date:_____________________