Pereira's Home Centre Credit Card Application

Please Tell Us About Yourself

Mr         Mrs         Ms         Miss         Dr        

First Name  Initials   Last Name

Date of Birth     19   Social Insurance Number

Drivers License Number           Home Telephone Number

Address   City

Province Postal Code   Number of Years There    

Own Rent Other (please explain)

Previous Address (If moved in the past 2 years)           

City   Province Postal Code

New Address (If moving)   

City    Province  Postal Code

Moving Date

Name of Nearest Relative Address

City       Province Postal Code

Phone Number

Please Tell Us About Your Job

Present Employer              Employed

Position         Business Telephone Number

City                 Gross Monthly Income            $

Previous Employer (If at current employer less than 2 years)  

From To Position

Business Telephone Number

Joint Applicant (Spouse) Information

Mr         Mrs         Ms         Miss         Dr        

First Name    Initials    Last Name

Date of Birth 19             Social Insurance Number

Present Address  Same as Above

City    Province   Postal Code

Present Employer   Employed        

Position     Gross Monthly Income $

Business Telephone Number

Financial Information

Bank or Trust Company      Address  

Credit Card Name   Valid Credit Card Number
Exp. Date                         Monthly Mortgage / Rent Payments    $

Credit Insurance Application
 
Would you like Credit Insurance?

Creditor's Group Insurance is available through Household Life Insurance Company and Amercian Bankers Insurance Company of Florida. The purchase of the insurance is voluntary and not a condition of obtaining credit. I am not eligible to apply for this insurance if the amount of credit exceeds $25,000.

The initial premium for this insurance is 69¢ per month per $100 of average daily outstanding balance on my Revolving Credit Account. This premium rate may change at any time and I will be notified at least 30 days in advance of it does change. Premiums and applicable sales tax will be billed to me in the monthly statements for the Account.

I acknowledge that I have read the "Notice of Proposed Credit Insurance" that I received with the Agreement referred to above.

Yes, with the above understanding, I hereby request enrollment in the Creditor's Group Insurance Plan.

No, I do not wish to enroll in the Creditor's Group Insurance Plan.

Please provide us with your email address to contact you in case further information is required.     * Your email address will not be used for solicitation purposes.