Application for Personal Fuel Account


Please check one site as your primary supplier:
Athabasca     Bonnyville / Cold Lake    Lac La Biche     Fort McMurray  
  Personal Information
Name:  *   Spouse's Name:
 *Please Note - if using AFFDA/Offroad number, account name applied for must read the same as legal name under tax-exempt #.
Address: Years at this address:
(1) Telephone: ()                (2) Telephone: ()                   Fax Number: ()          
Date of Birth::               S.I.N.::          Driver's License Number:
  Financial Information
Bank # 1:  
Branch Contact Name:                                Telephone: ()        
Chequing Account Number:               Savings Account Number:  
Bank # 2:  
Branch Contact Name:                                Telephone: ()        
Chequing Account Number:               Savings Account Number:  
  Credit References
  Creditor Name and Location (if Applicable) Balance Owing Monthly Payment
   $ $
   $ $
   $ $
I,      of 

certify that the above information is true and authorize yourselves obtaining any personal credit information through any credit bureau, credit reporting agency, government registry, private registry, or civil enforcement agency. I am personally responsible for any and all debts incurred as a result of this application, whether or not the invoice or work order is made out solely in my name. I will indemnify you, and see you paid for your account with respect to any order now or hereafter made. I understand that all invoices are due net 30 days. I agree to pay 2% interest (24% per annum) and service charges on all overdue invoices. I assume full responsibility for any costs incurred toward collection of the account including legal fees.

Dated at: in the province of this day of ,
(applicant)                 (witness)
  For Office Use Only
  Approval Signature   Comments:   Account Number  
  Date Created  
The above listed information is intended only for the purposes listed below, and will only be used when you first become a customer of Cougar Fuels Ltd. This information is used to confirm your identity and credit history; open an account with us; and to receive and provide products and ongoing services to you and may be disclosed to Petro-Canada.
►Submit this Form       ►Print this Form      ► If Fuel Cards required, please fill in another Form after this Submission.