Calgary Coop Fleet Application Where did you hear about us? Where did you hear about us? Applicant Information Legal Business Name * Operating/Trade Name (if applicable) Business Type * Corporation : Sole Proprietor Partnership Trust Non-Profit Other Business Registration Number * Registered Business Address * Mailing Address (if different) Phone Number * Existing Customer * yes No GST/HST number * Website * Date Established * Email * Bank Information Financial Institution * Branch Address * Phone Number * Account Manager/Contact * Trade References (minimum 2 trade references) Trade Reference 1 Reference #1 Company Name * Phone * Contact Person * Email * Trade Reference 2 Reference #2 Company Name * Phone * Contact Person * Email * Directors - Please complete below Note: List all individuals who are directors of the organization below. Director 1 Director 1 Name * Title * Residential Address * Ownership/Control % * DOB (MM-DD-YYYY) * Cell Phone * Director 2 Director 2 Name Title Residential Address Ownership/Control % DOB (MM-DD-YYYY) Cell Phone Director 3 Director 3 Name Title Residential Address Ownership/Control % DOB (MM-DD-YYYY) Cell Phone Director 4 Director 4 Name Title Residential Address Ownership/Control % DOB (MM-DD-YYYY) Cell Phone Beneficial Ownership Information (FINTRAC Requirements)-Schedule B Note: List all individuals who directly or indirectly own or control 25% or more of the entity. Beneficial Owner 1 Beneficial Owner 1 Name Residential Address Ownership/Control % Citizenship DOB (MM-DD-YYYY) Beneficial Owner 2 Beneficial Owner 2 Name Residential Address Ownership/Control % Citizenship DOB (MM-DD-YYYY) Beneficial Owner 3 Beneficial Owner 3 Name Residential Address Ownership/Control % Citizenship DOB (MM-DD-YYYY) Beneficial Owner 4 Beneficial Owner 4 Name Residential Address Ownership/Control % Citizenship DOB (MM-DD-YYYY) Authorized Signing Officers Signing Officer 1 Authorized Signatory 1 Name Title/Position Email Address Residential Address Ownership/Control % DOB (MM-DD-YYYY) Cell Phone Number Signing Officer 2 Authorized Signatory 2 Name Title/Position Email Address Residential Address Ownership/Control % DOB (MM-DD-YYYY) Cell Phone Number FINTRAC Identification & Verification The Applicant acknowledges and agrees that identity verification procedures may be conducted on all authorized signing officers, directors, beneficial owners, and other individuals as required by applicable laws and regulations, including the Proceeds of Crime (Money Laundering) and Terrorist Financing Act (Canada) and FINTRAC guidance. The Applicant agrees to provide valid government-issued identification and any supporting documentation reasonably requested for verification purposes. Verification may include review of identification documents, corporate records, ownership information, and other due diligence measures. Applicant Certification & Authorization The undersigned certifies that all information provided in this application and any supporting documentation is true, complete, and accurate to the best of their knowledge. The undersigned further represents that they are duly authorized to submit this application on behalf of the Applicant. The Applicant authorizes the creditor to obtain and exchange credit, financial, banking, trade, and other reasonably required information for the purpose of evaluating and administering credit. The Applicant agrees to promptly notify the creditor of any material changes to ownership, control, authorized signing authority, or other information contained in this application. Applicant Certification & Authorization The undersigned hereby expressly and specifically authorizes Foss National Leasing to request and obtain any credit, financial or other information concerning the undersigned or any transaction involving the undersigned which Foss desires in relation to the credit hereby applied for, and further authorizes and instructs any credit bureau, bank, financial institution, accountant or other person possessing any such information to communicate such information to Foss upon its request, both before, during and after the term of the said credit”. The undersigned agrees with communication in English. *I AGREE ANY LEASE OR SERVICE WILL BE USED BY MY COMPANY AND ITS EMPLOYEES ONLY INTITIALS * DATE * Authorized Signature By signing this application I give permission to Calgary Co-operative Association Limited to send marketing communications Legal Business Name * Authorized Signatory Name * Signature * Title * Date (MM-DD-YYYY) * Authorized Signatory Name Signature Title Date (MM-DD-YYYY)
