Personal Fuel Account

Personal Information

If using AFFDA/Offroad number, account name applied for must read the same as legal name under tax-exempt #.

First Name*

Middle Initial

Last Name*

Spouse's Name

Email*

Phone*

Driver's License #

Date of Birth*

S.I.N.*

Address*

Town / City*

Province*

Postal Code*

Years at Address

Email for Statements & Invoices

FINANCIAL INFORMATION

Bank Name*

Branch Location*

Branch Contact Name

Branch Phone

Chequing Account #

Savings Account #

CREDIT REFERENCES

Reference 1

Balance Owing

Monthly Payment

Reference 2

Balance Owing

Monthly Payment

Reference 3

Balance Owing

Monthly Payment

CREDIT AGREEMENT

I 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. Signing this application consents to Cougar Fuels Ltd. obtaining from, exchanging with or disclosing to other credit grantors and recognized credit bureaus any and all information concerning the application for the purpose of ensuring the accuracy of this information, conducting ongoing credit investigations, monitoring credit status and entering into and performing the agreement. This information may be disclosed to Suncor Energy Product Partnership.

I, (name of applicant)*

of (town of residence)*

Province*

Date*

Signature*

Sign here

FUEL ACCOUNT & CARD REQUIREMENTS

Current Fuel Supplier

Estimated Monthly Purchases

Credit Limit Required

Please call me to customize my cards for location and product access

PLEASE ADD RETAIL PUMP ACCESS

AFFDA #

Offroad # A

If numbers end in anything other than 01 or 06, the number is expired. Above number MUST be under the same name as the account name applied for.

FUEL CARDS REQUIRED — CLEAR

Clear Gas

How many cards

Clear Diesel

How many cards

Clear Gas / Diesel

How many cards

FUEL CARDS REQUIRED — DYED

Dyed Gas

How many cards

Dyed Diesel

How many cards

All Products

How many cards

PRE-AUTHORIZED DEBIT (PAD) PLAN

I/we authorize Cougar Fuels Ltd., and the financial institution designated (or any other financial institution I/WE may authorize at any time) to begin deductions as per my/our instructions for monthly regular recurring payments and/or one-time payments from time to time, for payment of all charges arising under my/our Cougar Fuels Ltd. account(s). Regular monthly payments for the full amount of services delivered will be debited to my/our specified account on the 27th day of each month or the closest business day to it. Cougar Fuels Ltd. provides a monthly statement showing the current amount owing. Cougar Fuels Ltd. will obtain my/our authorization for any other one-time or sporadic debits. This authority is to remain in effect until Cougar Fuels Ltd. has received written notification from me/us of its change or termination. This notification must be received at least ten (10) business days before the next debit is scheduled. I/We may obtain a sample cancellation form, or more information on my/our right to cancel a PAD Agreement at my/our financial institution or by visiting www.cdnpay.ca.

Name*

Date*

Address*

City / Town*

Province*

Postal Code*

Type Full Name*

Signature*

Sign here

Void Cheque or Bank Information Form*

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Attach VOID cheque or bank information form (PDF, JPG, or PNG)