Legal Name of Company:

Email Address:

Street Address:

City/Town:

Province/State:

Postal/Zip Code:

Phone #:

Number Of Years In Business:

Company President:

Accounts Payable Contact:

Phone #:

Bank Name:

Address:

City/Town:

Province/State:

Account Manager:

Phone #:

Trade References:

Name:

Phone #:

Fax #:

Name:

Phone #:

Fax #:

Name:

Phone #:

Fax #:

Insurance Information:

WE REQUIRE A CURRENT COPY OF YOUR INSURANCE CERTIFICATE SHOWING
POLICY NUMBER, EXPIRY DATE, AND ENDORSEMENT SHOWING BENLEA LEASING LIMITED "AS LESSOR" AND" AS ADDITIONAL INSURED"

INSURANCE COMPANY NAME:

INSURANCE AGENT:

POLICY NUMBER:

EXPIRY DATE:

I/WE AGREE TO THE FOLLOWING TERMS AND CONDITIONS:
1. TO NOTIFIY BENLEA LEASING LIMITED IMMEDIDATELY IF THERE IS ANY CHANGE IN YOUR INSURANCE INFORMATION AND TO FORWARD ALL RENEWALS AND ENDORSEMENTS IN A TIMELY MANNER.

2. A PAST DUE INTEREST CHARGE OF 2%PER MONTH WILL BE CHARGED ON ALL ACCOUNTS.

3. YOUR SIGNATURE AFFIXED HERETO IS AUTHORIZATION FOR A CREDIT INVESTIGATION AND CREDIT INFORMATION EXCHANGED IN CONNECTION WITH THIS APPLICATION.

4. ALL STATEMENTS MADE HEREIN ARE TRUE AND ACCURATE TO THE BEST OF MY KNOWLEDGE. BY SIGNING BELOW, I ACKNOWLEDGE THAT I AM AN AUTHORIZED REPRESENTATIVE OF THE ABOVE COMPANY WITH THE AUTHORITY TO SIGN LEGAL BINDING DOCUMENTS FOR THE COMPANY.

DATE:

SIGNED:

POSITION: