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LESSEE INFORMATION

Legal Name:
Address:
Telephone:
City / Province:

*Required
Cellular:
Postal Code:
Fax:
Contact:
Email:
Type of business:
Since:

BANK INFORMATION (Include a sample cheque)

Commercial Personal

Commercial Personal

Name:
Name:
Address:
Address:
City / Province:
City / Province:
Postal Code:
Postal Code:
Telephone:
Telephone:
Fax:
Fax:
Account No.:
Account No.:
Line of credit ($):
Line of credit ($):
Utilised ($):
Utilised ($):

SUPPLIER INFORMATION

Name : Pierquip Inc.
Program : Crédit-bail
Adress : 16079 Curé-Labelle
Contact : Marie-Claude Jutras
City/Province : Mirabel, Qc
Telephone : 450.438.6400
Postal Code : J7J 2G6
Fax : 450.438.1090

EQUIPEMENT DESCRIPTION (Attach quote to the credit application)

Quantity
Description
Price

PAYMENT TERMS

Total cost ($):
Term (months):
Deposit ($):
Exchange value ($):
Financed amount ($):

PERSONAL INFORMATION

Name:
Name:
Address:
Address:
City / Province:
City / Province:
Postal Code:
Postal Code:
Telephone (home):
Telephone (home):
Social Insurance Number:
Social Insurance Number:
Date of birth:
Date of birth:
Own? (Y/N): Yes No
Own? (Y/N): Yes No
Value of real estate:
Value of real estate:
Since:
Since:
Mortgage balance ($):
Mortgage balance ($):

CONSENT AND SIGNATURE

Signature
*Required

Enter the security code above: