Finance Application

LESSEE INFORMATION

Legal Name:*

First Last Suffix

Address:*

City:*

Province:*

Postal Code:

Type of business:*

Telephone:*

Mobile:

Fax:

Since:

Bank Information

Type:

Commercial
Personal

Account owner name:

First Last Suffix

Address:*

City:*

Province:*

Postal Code:

Telephone (Mobile):

Telephone (Home):

Fax:

Account Number:

Line of credit ($):

Utilised ($):

SUPPLIER INFORMATION

Company: Pierquip Inc.
Adress: 16079 Curé-Labelle
City/Province: Mirabel, Qc
Postal Code: J7J 2G6
Contact : finance@pierquip.com
Telephone : 450.438.6400
Fax : 450.438.1090

EQUIPEMENT DESCRIPTION

Attach quote to the credit application

Quanity:

Description:

Price ($):

PAYMENT TERMS

Total Cost ($):

Deposit ($):

Financed Amount ($):

Term (Months):

Exchange Value ($):

PERSONAL INFORMATION

Name 1:

First Last Suffix

Address:*

City:*

Province:*

Postal Code:

Telephone (Mobile):

Telephone (Home):

Social Insurance Number:

Date Of Birth:

Own? (Y/N):*

Yes
No

Value of Real Estate:

Mortgage balance ($):*

REQUIRED DOCUMENTS

Please upload a void cheque and quote below.

Documents

Drop files here or

Max. file size: 2 MB, Max. files: 6.

CONSENT AND SIGNATURE

The undersigned certifies that the information provided is true and accurate. By signing below, I / we agree that Pierquip Inc (And finance companies with whom it does business) gets any credit agency or any guarantor to the credit application with financial ties with the applicant any information required at all times and in connection with this credit application and consent to full disclosure of this information at any time.

Signature:*