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Please print this document (select Print from the File menu or from the toolbar in most web browsers), complete it, sign it, and return it by facsimile to (403) 285-8830 or by mail to

DRC Instruments
54 Martindale Drive NE
Calgary, AB T3J 2V4

DRC Instruments Commercial Credit Application

Date:

 

Client Information

Legal Business Name:   Phone: (    )               
Address:  

 

 

Date of Incorporation:  
Change of Ownership: [ ] Yes [ ] No
[ ] Current Client [ ] Previous Client
 

Corporate Structure

[ ] Corporation [ ] Partnership [ ] Proprietorship [ ] Other: _________
Authorized Bank Signing Officer Name:                         Title:                        
Authorized Bank Signing Officer Name:                         Title:                        
 

Trade References

1 2 3
Company      
Address  

 

 

 

 

 

Phone/Contact      
 

Bank Information

Section A Bank and Account Number  

How long at this branch?

 (If less than 2 years, complete section B also)

Address

 
City   Province/Postal Code  

Contact name

 

Phone number

 

Attach any relevant banking information (eg. loans, NSFs, bankruptcy, etc.)
Section B: Prior banking information Bank and Account Number  

How long at this branch?

 

Address

 
City   Province/Postal Code   

Contact name

 

Phone number

 

Attach any relevant banking information (eg. loans, NSFs, bankruptcy, etc.)
 

Shareholder Information

#1)     Name:   Title  

Address

 

  

Ownership:      %

Phone

(____)___________

S.I.N.

 

Birth Date

 

Background

 

Bank

  Account Number  

Address

 
City   Province/Postal Code  

Contact name

 

Phone number

 

Attach any relevant banking information (eg. loans, NSFs, bankruptcy, etc.)
#2)     Name:   Title  

Address



 
Ownership:     %

Phone

(____)___________

S.I.N.

  

Birth Date

Background

 

Bank

  Account Number  

Address

 
City   Province/Postal Code   

Contact name

 

Phone number

 

Attach any relevant banking information (eg. loans, NSFs, bankruptcy, etc.)
 
The undersigned certifies the above information to be true and correct. By signing below, I/we consent to the obtaining from any credit reporting agency or credit grantor, such information as DRC Instruments and/or its assignees may require at any time in connection with the credit hereby applied for and consent to the disclosure at any time of any information concerning the undersigned to any credit reporting agency or to any credit grantor with whom the undersigned has financial relations.
Authorized signature(s) of clients(s)  
X X X
Signature Signature Signature
     
Print Name Print Name Print Name
     
Date Date Date

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Copyright © 1997, 1998 Chad Conrad and DRC Instruments ALL RIGHTS RESERVED