Mitsubishi HC Capital Canada Leasing, Inc. www.mhccna.com	CONTRACT NUMBER

CREDIT APPLICATION
(Complete in block letters)

LESSEE INFORMATION Send Credit Applications to: credit_en@mhccna.com
Legal Name (Company):
Address:	Cellular:
City / Province:	Email:
Postal Code:	Website:
Type of business:	Other phone:
Since:	Fax:
BENEFICIAL OWNERSHIP (Control more than 25% of a company’s shares or voting rights)
If any beneficial owners over 25% are identified, please provide their legal names and addresses.

BANK INFORMATION (Include void cheque)
Commercial	Personal	Commercial	Personal
Name:	Name:
Address:	Address:
City / Province:	City / Province:
Postal Code:	Postal Code:
Phone:	Phone:
Fax:	Fax:
Account No:	Account No:
Line of credit ($):	Utilized ($):	Line of credit ($):	Utilized ($):

SUPPLIER INFORMATION
Name:	Program No:
Address:	Contact:
City / Province:	Phone:
Postal Code:	Fax:

EQUIPMENT 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:
Phone:	Phone:
SIN:	DOB:	SIN:	DOB:
Owner? (Y/N)	Owner? (Y/N)
Real Estate value ($):	Real Estate value ($):
Mortgage balance ($):	Mortgage balance ($):

CONSENT PERSONAL INFORMATION AND SIGNATURE: The undersigned confirms that the above information is true. In addition, it authorizes Mitsubishi HC Capital Canada, Inc., its subsidiary Mitsubishi HC Capital Canada Leasing, Inc. and / or Mitsubishi HC Capital America, Inc. (hereinafter referred to collectively as "MHCCA"), or any other financial institution, to request and exchange any information regarding solvency, particularly with respect to applications to credit bureaus and their full disclosure at any time. The undersigned acknowledges that MHCCA has a serious and legitimate interest in collecting personal information, directly from the undersigned or from third parties, and that this collect of information enables the undersigned to operate its business. The undersigned acknowledges that MHCCA can establish a file with the personal information collected. The file thus established will be kept at one of MHCCA's places of business and may only be consulted by authorized persons. The undersigned will have the right to access this file by making a written request in this regard. The undersigned also acknowledges that MHCCA may disclose any financial information or other material in connection with the granting of such assignment. This consent may be withdrawn at any time, by written communication addressed MHCCA.

Signature (A)	Signature (B)	Date