Application for Account

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COMPANY DATA

Company Name:

Current Address:

Credit Terms

Monthly

City/Town:

Province:

Postal Code

Telephone:

Cell Phone:

Fax:

Delivery Directions

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ACCOUNTS PAYABLE INFORMATION

Contact Name:

Contact Phone:

Fax:

Email Address:

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OWNER/PRINCIPALS

Name:

Address:

Name:

Address:

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REFERENCES

Bank Name:

Branch Location:

Telephone:

Trade Reference 1

Address

Phone:

Fax:

Trade Reference 2

Address:

Phone:

Fax:

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THE UNDERSIGNED CERTIFIES THE ABOVE INFORMATION TO BE TRUE AND AFFIRMS THAT ANY CREDIT GIVEN TO ME IS EXTENDED UPON THE BASIS OF SUCH INFORMATION.

The undersigned consents to the obtaining of credit and/or personal information as may be required at any time in connection with the credit hereby applied for or any renewal or extension thereof and to the disclosure of any credit information concerning the undersigned to any credit reporting agency or to any person with whom the undersigned has or proposes to have financial relations. We will retain such information on file.

The undersigned agrees to pay a monthly credit charge composed of interest only at the rate of 2% per month (26.8% per annum) compounded monthly on any overdue balance. Dave Moore Fuels Ltd, may upon one month's notice cancel this agreement or vary the terms hereof and the customer shall remain responsible for all indebtedness. Continued use of this charge account by the customer following notification that the terms hereof have been varied will be deemed acceptance by the customer of such new terms as of the effective date mentioned in the notice both with respect to indebtedness incurred subsequent to such date and unpaid indebtedness at such date.

Applicant Name:

Date Requested:

Date Credit Approved: