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1235 North Service Rd. W.,
Suite 100
Oakville, ON L6M 2W2
Fax Cover Sheet
DATE:
TIME:
TO:
PHONE:
FAX:
FROM:
PHONE:
FAX:
1-866-689-0433
1-877-500-5356
RE:
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Number of pages including cover sheet:
Message:
CONFIDENTIALITY NOTICE: This fax cover sheet and the documents accompanying this fax transmission may contain confidential
information belonging to the sender which is legally privileged. The information is intended only for the use of the individual or entity named
above as recipient. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution or the taking of any
action in reliance on or regarding the contents of this faxed information is strictly prohibited. If you have received this fax in error, please
notify us immediately by telephone to arrange for return of the original documents to us.
AGRICREDIT ACCEPTANCE CANADA,
A DIVISION OF DE LAGE LANDEN FINACIAL SERVICES CANADA INC.
APPLICANT’S NAME (Last, First, Middle)
SOCIAL INS. NO.
APPLICATION FOR CREDIT
DATE OF BIRTH
HAVE YOU EVER USED AAC BEFORE?
NO
MAILING ADDRESS
CITY
PHYSICAL ADDRESS OF RESIDENCE (If Different Than Mailing Address)
COUNTY (REQUIRED)
Married
WORK OR CELL TELEPHONE NUMBER
G
NAME OF NEAREST RELATIVE NOT LIVING WITH YOU
E
LEGAL NAME OF BUSINESS UNDER WHICH YOU OPERATE
Unmarried
PROVINCE
INDIVIDUAL
E
YRS AT CURRENT ADDRESS
Separated
CITY
TYPE OF BUSINESS
POSTAL CODE
E-MAIL ADDRESS
MARITAL STATUS
HOME TELEPHONE NUMBER
N
PROVINCE
YES
TELEPHONE NUMBER
RELATIONSHIP
LIMITED PARTNERSHIP
LIMITED LIABILITY COMPANY (LLC)
GENERAL PARTNERSHIP
OTHER (Please specify) _________________________
CORPORATION
FED TAX ID#
IF BUSINESS TYPE IS PARTNERSHIP, LLC OR CORPORATION, PLEASE PROVIDE INFORMATION FOR ALL PARTNERS, OWNERS OR OFFICERS BELOW
OWNER/PARTNER/OFFICER
SOCIAL INS. NO.
RESIDENCE (CITY, PROVINCE)
DATE OF BIRTH
% OWNED
TELEPHONE
TITLE
R
A
BUSINESS ADDRESS (CHIEF EXECUTIVE OFFICE)
L
EQUIPMENT USE: FARM
%
CUSTOM WORK
CITY
_%
COUNTY
FORESTRY
% COMMERCIAL
POSTAL CODE
PROVINCE
% INDUSTRAIL
% RENTAL YARD
% PERSONAL
%
% (Please describe)
OTHER
YEARS IN BUSINESS
COUNTY & PROVINCE IN WHICH EQUIPMENT WILL BE KEPT
PRIMARY LENDER NAME
CITY, PROVINCE
YEARS
TELEPHONE
CONTACT NAME
OPERATING
MACHINERY
BANK
CITY, PROVINCE
EMPLOYER
SOURCE OF OTHER INCOME
AMOUNT
YEARS
ANNUAL GROSS INCOME
SOURCE OF OTHER INCOME
$
FREQUENCY
AMOUNT
$
FREQUENCY
COMPLETE THE SECTION BELOW IF YOU HAVE INCOME FROM AGRICULTURE
A
DO YOU FARM?
FULL TIME
PART TIME
KIND OF CROP
G
NO. OF ACRES
# OF ACRES OWNED
# OF ACRES RENTED
INCOME DATE
ESTIMATED AMOUNT
OTHER INCOME
AMOUNT
SEASONAL
$
$
INCOME
$
$
IF LOAN IS > $100,000
AND < $250,000
TOTAL ASSETS
$
TOTAL LIABILITIES
$
STATEMENT AS OF (MM/DD/YY)
Have I/we had any unsatisfied judgments rendered against me/us in the past 7 years, had equipment repossessed in the past 7 years, or been declared
Please attach an explanation for any yes answer.
bankrupt in the past 10 years? (yes/no)
By signing below, Applicant: (1) affirms that the information provided in this application, including the reverse side if completed, is true and correct and given for
the purpose of obtaining credit; (2) understands that if credit is extended, the Agricredit Acceptance Entities will rely on such information to secure the
indebtedness; (3) authorizes references to provide all relevant information to the Agricredit Acceptance Entities; (4) authorizes the Agricredit Acceptance
Entities to investigate and obtain reports concerning credit history; and (5) consents to and accepts this as written notice of the Agricredit Acceptance Entities
obtaining, collecting, using, disclosing, investigating, retaining or exchanging Personal Information about Applicant and information concerning Applicant’s
credit experience with Agricredit Acceptance Entities and their decision whether or not to extend any credit from, to or with any other person in connection with
any arrangement Applicant has with or through the Agricredit Acceptance Entities or Applicant may wish to establish with any Agricredit Acceptance Entities in
accordance with the Privacy Practices Notice that accompanies this Application. Applicant acknowledges receipt of such Privacy Practices Notice and waives
any right to confidentiality that may exist with respect to the release, exchange, retention or sharing of Personal Information about Applicant and Applicant
agrees that the Agricredit Acceptance Entities are authorized to retain and use any information obtained as part of the application process whether or not the
requested credit is granted. All capitalized terms used in this Application shall have the meanings attributed to them in the Privacy Practices Notice that
accompanies this Application.
If this application amount PLUS all existing debt payable to Agricredit Acceptance Entities is $250,000 or more or
upon request of Agricredit Acceptance, then please provide the additional information requested on the next page.
Signature
Date
Signature (Partner/Co-signor/Guarantor)
Date
AAC 3942 Cdn (6/04)
AGRICREDIT ACCEPTANCE CANADA,
A DIVISION OF DE LAGE LANDEN FINACIAL SERVICES CANADA INC.
APPLICATION FOR CREDIT
Two years of Financial Statements (Balance Sheet and Income Statement)
necessary if:
1) this application amount PLUS all existing debt payable to Agricredit is $250,000 or more, OR
2) upon request of Agricredit or any of its affiliates.
If the above requested information is not available, AAC would consider substituting two years history of the most
recent Tax Returns, and the following financial information.
CASH
ACCOUNTS PAYABLE
RECEIVABLE
OPERATING LOANS
N
STOCKS, BONDS, CERTIFICATES OF DEPOSIT, ETC.
MACHINERY LOANS
A
MACHINES AND EQUIPMENT
AUTO & TRUCK LOANS
N
AUTOS AND TRUCKS
REAL ESTATE LOANS
C
LIVESTOCK
UNSECURED & CREDIT CARDS
F
I
I
CROPS FOR SALE: HARVESTED YES
NO
TAXES PAYABLE
A
BUILDINGS AND LAND NO. OF ACRES
MONEY OWED TO OTHERS
L
OTHER ASSETS
OTHER LIABILITIES
TOTAL ASSETS
TOTAL LIABILITIES
CONTINGENT
LIABILITIES/GUARANTIES
If the requested credit is granted, applicant agrees to provide updated Financial Statements annual, thereafter.
COMPLETE THE FOLLOWING SECTION IF EQUIPMENT WILL BE USED FOR
CUSTOM, COMMERCIAL, FORESTRY, OR OTHER
C
WILL EQUIPMENT BE USED:
O
SPECIFIC LINE OF BUSINESS
FULL TIME
PART TIME
PRIMARY CONTRACTOR
M
%
SLACK MONTHS:
IF SUBCONTRACTOR, NAME ADDRESS OF PRIME CONTRACTOR
SUB CONTRACTOR
M
ESTIMATED MONTHLY GROSS
E
IF FORESTRY, PLEASE LIST THE MILLS CURRENTLY BUYING YOUR LOGS OR SERVICES:
R
NAME
C
I
A
L
AAC 3942 Cdn (6/04)
$
ADDRESS
CONTACT NAME
TELEPHONE NUMBER
VOLUME PER WEEK
PRIVACY PRACTICES NOTICE
The Creditor is providing this information to you in compliance with Canadian privacy law. Please read this sheet
carefully and retain it for your reference.
Federal and Provincial privacy laws require individuals, partnerships, corporations and other "organizations" to adhere
to 10 principles of fair information management when collecting, using and disclosing information about an identifiable
individual ("personal information") in the course of commercial activities.
The requirements imposed on organizations include:
•
identifying the purposes for which organizations collect, use and disclose personal information;
•
obtaining consent to the collection, use and disclosure of an individual's personal information; and
•
limiting the collection, use, disclosure and retention of personal information to that which is necessary for the
purposes identified by organizations and authorized by individuals.
The purposes for which the Creditor collects and uses personal information and a description of the organizations to which
the Creditor may disclose personal information are documented on its Credit Application. The Creditor also obtains consent
to the collection, use and disclosure of personal information on its Credit Application.
If you authorize the Creditor to collect your personal information, the Creditor will provide you with access to that
information on your request. If you believe that your personal information on record at the Creditor is inaccurate or
incomplete, the Creditor will investigate and make any corrections or additions to the information that its investigation
demonstrates are necessary.
For more information about the Creditor's privacy policy and practices, information about any personal information
relating to you that the Creditor has on record, access to your personal information held by the Creditor, or to make an
inquiry or request an investigation into the accuracy or completeness of personal information held by the Creditor,
please contact our Privacy Officer at 1235 North Service Road West, #100, Oakville, Ontario, L6M 2W2 or (905) 4653160, ext. 2237 / toll free 1-877-500-5355, ext. 2237.