Fas Gas Plus

Retailer Application Form

	Please ensure you complete all fields of information before submitting your applications. Failure to provide adequate information will delay our ability to process your application in a timely manner
	PERSONAL INFORMATION
Last Name
First Name
Middle Name
	Home Address
Street
City
Postal Code
Social Insurance Number
Date of Birth
Home Phone:
Cell Phone:
Work Phone:
Email Address:
Drivers License Number
Province Issued
Date Issued
	BACKGROUND
Are you currently exploring any other Retail Opportunities? If Yes, where?
Have you ever worked for Parkland/FasGas/Short Stop?	Yes No
How did you learn about Parkland Retail Opportunities?	Referral Other
Please Specify
	Describe three qualities that will ensure you are a successful retailer.
1.
2.
3.
	BUSINESS INFORMATION
Do you own any other Businesses?	Yes No
What percentage of your time is presently devoted to this business?
Are you presently providing products, goods, or services to Parkland Industries or any other affiliates?	Yes No
If Yes, where?
Is there anything that may adversely affect your ability to operate a successful retail service business?	Yes No
If Yes, please explain:
If you are successful in obtaining a Parkland Industries Ltd. retail opportunity would you discontinue your involvement in this business?	Yes No
Describe the successes in business ventures, if any, that you have experienced in the past including specialized training (college/university/trade) and any previous retail, administrative, supervisory or other relevant experience.
Are you a member of any business community organizations or trade groups? Please Explain:
	BUSINESS REFERENCES
Company Name
Contact Name
Position/Title
Business Phone #
Company Name
Contact Name
Position/Title
Business Phone #
Company Name
Contact Name
Position/Title
Business Phone #
	WORK HISTORY
	Current Employer
Company Name
Type of Business
Position
Supervisor
Position/Title
Phone
Dates of Employment
Salary/Wages
Responsibilities
	Previous Employer
Company NamePE
Type of Business
Position
Supervisor
Position/Title
Phone
Dates of Employment
Salary/Wages
Responsibilities
Reason for leaving
	GENERAL INFORMATION
Do you have any lawsuits pending?	Yes No
Do you have any judgements/liens currently pending against you?	Yes No
If yes, please explain:
Do you have any criminal convictions for which pardon has not been granted? (Be prepared to submit a Criminal Record Check)	Yes No
Has any company that you have owned or been associated with, even declared bankruptcy?	Yes No
Have you ever declared personal bankruptcy?	Yes No
	What areas are you interested in?
Choice 1
Choice 2
Choice 3
Are you willing to relocate?	Yes No
	STATEMENT OF NET WORTH (MANDATORY)
	Assets
Cash in Bank $
Term Deposits/GICs
Securities/Bonds/RRSP $
Accounts/Notes/Loans Receivable $
Real Estate/Mortgage Receivable $
Other Assets $
Total Assets $
	Liabilities
Accounts, Notes and Loan Payable $
Real Estate and Mortgage Payable $
Other Liabilities $
Total Liabilities $
Total Net Worth = (Total Assets-Total Liabilities) $
How much liquid cash investment do you expect to supply? $
	CREDIT REFERENCES
Bank Name
Branch
Account Number
Phone
Bank Name
Branch
Account Number
Phone
Bank Name
Branch
Account Number
Phone
DECLARATION (*)	By checking the box I submit the following information as my complete and true personal and financial condition as the date shown below. In accordance with existing laws, I expressly authorize any past or present employer, business partner, any law enforcement agency, federal, provincial, or municipal department or any person who has knowledge of my character, work experience or criminal records to release the information to Parkland Industries Ltd. I agree to supply statements from my professional advisors (e.g. banker, broker, accountant, or attorney) verifying the financial information herein. All information provided in this form will be treated as confidential. Invalid Input
Security Code	Please enter the correct security code

PERSONAL INFORMATION

BACKGROUND

BUSINESS INFORMATION

BUSINESS REFERENCES

WORK HISTORY

GENERAL INFORMATION

STATEMENT OF NET WORTH (MANDATORY)

CREDIT REFERENCES