XPRESS PASS Card Application Business Information Legal Business Name * Doing Business As First Name * Last Name * Email * Business Phone * Business Fax Business Street Address * Address Line 2 City Province * - Select -AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon U.S Postal Code * For Example: A1A 1A1 Financial Statement Available * - Select -YesNo Have you been in business more than a year but at your current address for less than 12 months? * - Select -YesNo Previous Address Street Address Address Line 2 City Province - None -AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon U.S Postal Code For Example: A1A 1A1 Billing Information Billing Contact First Name Billing Contact Last Name Billing Phone Billing Fax Billing Email Postal Code For Example: A1A 1A1 Same as Business Address Same as Business Address Billing Street Address Address Line 2 City Province - None -AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon U.S Additional Information GST/HST number * Enter your company's GST or HST number (#########) Legal Structure * - Select -CorporationGovernmentNon ProfitPartnershipProprietorshipOther Years Incorporated * - Select -Less than 12 months12345678910111213141516171819202122232425more than 25 Card Usage Type * - Select -Fuel, Fluid, Wash OnlyUnrestricted Estimated Monthly Fuel & Service Expenses * $ Estimated Monthly Fuel Volume * Value in Litres Number of Cards Requested * Bank Information Please provide the following Bank and Account information for the primary Financial Institution used by your business. This information will be used for Pre-Authorized Debit payments (PAD). Bank Name * Branch Street Address City Province - None -AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon U.S Postal Code For Example: A1A 1A1 5-DIGIT Branch Transit Number * Bank Account Number * Name on Bank Account * Branch Phone * Branch Fax Number Commercial Credit References Please provide the two Trade References for your company below. Credit Reference 1 Commercial Name * First Name * Last Name * Address * Address Line 2 City * Province * - Select -AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon U.S Postal Code * For Example: A1A 1A1 Phone * Credit Reference 2 Commercial Name * First Name * Last Name * Address * Address Line 2 City * Province * - Select -AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon U.S Postal Code * For Example: A1A 1A1 Phone * Personal Credit Information In order to process your application, we will need to obtain a consumer credit report on a title-authorized representative for your company; such as President/Chairman, Partner, Vice President, Owner or Treasurer/Financial Officer. The Personal credit history of the person provided below will be used in making a credit decision. First Name * Last Name * Middle Name Home Address * Address Line 2 City * Province * - Select -AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon U.S Postal Code * For Example: A1A 1A1 Phone * Date of Birth * Terms and Conditions The Customer applies to Foss National Leasing Ltd. (Foss) for the Xpress Pass Card. The Customer consents to Foss' collection, use and sharing of the personal information (the "Cardholder Information") provided in this application or complied internally by either Foss or its third party service providers for the purpose of offering the Customer an Xpress Pass card. Pursuant to the Xpress Pass Card, the Customer may charge goods and services up to the credit limit set by Foss and must pay the full balance as shown on each monthly billing statement, according to the general terms and conditions of the agreement (the "Cardholder Agreement") relating to the Xpress Pass Card, a copy of which will be sent to the Customer with its credit card upon approval of this Application: and upon approval of this Application, the Customer agrees with Foss to abide by and be bound by the terms and conditions set out in the Agreement. By signing this Application the Customer represents and warrants that: (a) it is a valid business entity or a self-employed professional or business person, and duly registered as such under all applicable laws; (b) all purchases made on the Account, if approved, will be for business purposes and shall not include personal, family, or household use; (c) the individual signing the Application is an authorized representative of the business with authority to enter into contractual agreements; and (d) the Cardholder Information is complete and accurate. Foss will, from time to time, (i) use or disclose the Cardholder Information, and information obtained subsequently from any source with the Customer's consent (collectively the "Information") to obtain credit reports from credit reporting agencies and to contact credit references and other sources disclosed herein as part of its assessment of the Information; and (ii) may transfer the Information to a third party as part of a transfer of all or part of the Foss' charge card or credit card business (collectively the "Purposes"). Foss may provide some or all of the Information to third party service providers who process the Information only in furtherance of the Purposes or in accordance with applicable law. For any questions regarding the Information or Purposes, please consult our Privacy Policy at fossnational.com/terms-conditions or call 1-800 461 3677. The Customer consents to Foss' use of the Information for the Purposes or in accordance with applicable law. Customer also understands that credit on the Xpress Pass Card, once approved, will be extended by Foss, and that there will be no-binding contract between the Customer and Foss until Foss approves and accepts this Application. All Applicants are deemed to be authorized signatories of the Customer and acknowledge and agree that they are responsible for all purchases on the Xpress Pass Card made by the Customer. Authorized Signature Note: By submitting this form, the applicant agrees that: The information provided is true and accurate. It has been provided for the purposes of review of this application and, if said application is accepted, for the subsequent handling of the applicant's client file (credit-billing-collection). For these purposes, the applicant authorizes Foss National Leasing Ltd. (Foss) to carry out, now and at any time in the future, any and all of the usual credit investigations with any third party, and also agrees that Foss may request, obtain and communicate to any such third party, any personal information regarding the applicant. The applicant furthermore agrees that Foss may provide access to and communicate personal information contained in the applicant's client file to any credit reporting agency, person or firm with whom the applicant has or did have financial relations. The applicant hereby agrees to promptly inform Foss of any change with respect to the personal information provided herein and the applicant further understands that Foss reserves the right to apply credit restrictions at any time. The applicant accepts and agrees to be bound by the terms and conditions governing the use of Xpress Pass Card issued from time to time by Foss for any and all purchases made with the card(s) at all participating retailers. The personal information contained herein will be made accessible to employees, mandatories or agents of Foss when necessary for the performance of their duties, and a client file will be held at Foss' offices situated at p.p1 {margin: 0.0px 0.0px 0.0px 0.0px; font: 12.0px Helvetica} 25 Commerce Valley Dr. W, Markham, Ontario. The applicant acknowledges and understands that he/she has a right of access to the personal information contained in their file and a right of rectification. The applicant is duly authorized to complete the application on behalf of this corporation, partnership or proprietorship and confirms that these cards will be used for business purposes. p.p1 {margin: 0.0px 0.0px 0.0px 0.0px; font: 12.0px Helvetica} Signer's First Name * Signer's Last Name * Title * Signer's Phone * Signer's Email * I understand all invoices will be sent electronically and payments will be made by Pre-Authorized Debit (PAD) * I understand all invoices will be sent electronically and payments will be made by Pre-Authorized Debit (PAD). I have read and accept the Terms and Conditions above * I have read and accept the Terms and Conditions above
