PROPANE CREDIT APPLICATION

actton super-save gas stations ltd. 19395 no. 10 Highway, surrey, British columbia, canada v3s 6K1 telephone: (604) 533-4423 • Facsimile: (604) 534-5867 STATION NUMbER FOR OFFICE USE ONLY RECORD #: CARDLOCk #: COMMERCIAL #: propane CreDIT applICaTIon ACTTON SUPER SAVE GAS STATIONS LTD. (herein called SUPER SAVE) COMPANY INFORMATION reGistered BusiNess Name of compaNY address for iNvoices aNd statemeNts BusiNess pHoNe Head office address (if differeNt tHaN aBove) if a suBsidiarY, please state pareNt corporatioN Name used oN BaNk accouNt bANk NAME AND ADDRESS/CITY NAMES OF PRINCIPALS/OFFICERS 1. 2. coNtact persoN: Name NAMES OF TRADE/SUPPLIER REFERENCES 1. 2. 3. PERSONAL INFORMATION surName propane only (PLEASE TYPE OR PRINT IN bLOCk LETTERS) trade Name citY/toWN proviNce tYpe of BusiNess ■ ■ ■ proprietorsHip partNersHip corporatioN postal code Year BusiNess started or iNcorporated citY/toWN proviNce postal code otHer super save accouNts ■ Yes ■ No accouNt No. PHONE ACCOUNT NO. TITLE HOME ADDRESS SOCIAL INSURANCE NO. bIRTHDATE m m d d Y Y address pHoNe ADDRESS/CITY PHONE (PLEASE TYPE OR PRINT IN bLOCk LETTERS) first Name aNd iNitial social iNsuraNce No. street address / mailiNG address citY/toWN proviNce postal code resideNce pHoNe BusiNess pHoNe Years at preseNt address ■ ■ oWN reNt m BirtHdate d Y BaNk Name aNd address/citY pHoNe accouNt No. preseNt emploYer Name aNd address occupatioN leNGtH of time ■ ■ ■ permaNeNt temporarY seasoNal Name of spouse Name/address/pHoNe of Nearest relative Not liviNG WitH You relatioNsHip previous address/citY Years at previous address OFFICE USE ONLY credit limit _________________ price code ________________ $ ____________________________________________________________ cardlock cards full-serve cards ■ Quantity _____________________ ■ Quantity _____________________ the applicants authorize the corporation to obtain such credit reports or other information as may be deemed necessary in connection with the establishment and maintenance of a credit account or for any other direct business requirement for any applicants listed below, which may assist the corporation in making a decision on this application. this consent is given pursuant to chapter 78, section 12, of the credit reporting act, r.s.B.c. 1979. Payment must be received by SUPER SAVE, within 30 days from the date of invoice. Interest shall be charged and payable on all amounts not paid within the 30 days of invoice date at the rate of 24% per annum (or such a rate as SUPER SAVE shall set from time to time) on such balance which is outstanding including any interest unpaid. Discounts not applicable if Account past Due. total estimate moNtHlY purcHases $ ___________________________ approved BY _______________________________________________ siGNature ______________________________________________________________________ Name ____________________________________________________________________________ please priNt title __________________________________date _____________________________________ CUSTOMER NAME: __________________________ APPLICATION INFORMATION CARDLOCK (SELF-SERVE) PROPANE ONLY Please fill in each section and/or STATION CHARGE CARD (FULL SERVE) PROPANE ONLY Please fill in each section Number Of Vehicles _________________________________ Number Of Vehicles _________________________________ Number of Cards Required __________________________ Number of Cards Required __________________________ Do you use unit numbers? (must be keyed in at Cardlock) Unit Numbers ________________________________________ Yes ■ ■ No Do you require a mileage report? (Odometer reading must be keyed in at Cardlock every time in order to receive this report) Charge Options: Which of the following products do you wish to charge to your station card? Credit for gas is not available. ■ Estimated monthly purchases: Yes ■ No ■ ■ ■ Propane Oil (includes Transmission and Brake Fluid) Windshield Washer Estimated monthly purchases: $__________________________________ $__________________________________ Please specify any other propane requirements. Allow 3 - 4 weeks for processing of application and issue of cards. For insurance purposes the self serve Cardlock Cards must be picked up at a Cardlock location by the drive responsible for fueling. Please check which Cardlock location you would find the most convenient. ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ 100 mILE hOUSE bOSTON bAR bURNAby bURNAby bURNAby CAChE CREEK COqUITLAm DELTA DUNCAN KAmLOOPS KAmLOOPS KAmLOOPS KELOwNA KELOwNA mAPLE RIDGE mERRITT NANOOSE bAy -Cariboo hwy. -Trans Canada hwy. -6th & Edmonds -Kingsway & mcPhearson -hastings & madison -hwy. 97 North -Lougheed & Rousseau St. -80th & 120th -Allenby Rd. off Trans Canada hwy. -Tranquille at Clapperton -Summit Dr. off Columbia St. -branch Office -hwy 97 and mills Rd. -hwy 97 South near westside Dr. -205th & Lougheed -Nicola Ave. at margaret -E. Island hwy. 104 - 5th Street 48100 Trans Canada hwy. 7377 6th St. 5608 Kingsway 4295 East hastings 1592 hwy. 97 North 750 Lougheed hwy. 7812 Scott Road 2999 Allenby Rd. 280 Tranquille Road 1320 Summit Drive 10030 Durango Road 2620 hwy 97 N. 608 hwy. 97 S. 20522 Lougheed hwy. 2439 Nicola Ave. 1660 E. Island hwy. ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ PENTICTON PRINCE GEORGE PRINCE GEORGE qUESNEL REVELSTOKE RIChmOND SALmON ARm SURREy SURREy SURREy VERNON VANCOUVER VANCOUVER VICTORIA wESTbANK whITEhORSE wILLIAmS LAKE -Channel Pkwy. at Green mtn. Rd. -Continental way at 97 S. -Victoria St. at 10th Ave. -On N. Cariboo bay -hwy #1 at 23rd N. westminster hwy & #5 Rd. -On hwy 1 -86th Ave. & 120th St. -#10 hwy. & 194 St. -husky - at 80th Ave. -32nd St. at 36th Ave. -12th & Clark -1st & Renfrew -Government at Princess -Dobbin & Elliot -2 mile & Industrial Road -1708 S. broadway Lt. 47, Green mtn. Rd. 4832 Continental way 950 Victoria St. 914 N. Cariboo hwy 122 - hwy 23 North 6000 - #5 Rd. 50 - 3rd St. N.E. 12087 86th Ave. 19415 Langley by-Pass 7999 King George hwy 3603 - 32nd St. 1317 East 12th Ave. 1616 Renfrew 2122 Government St. 2525 hwy 97 N. 107 Industrial Rd. 1708 S. broadway