Single Application

Please do not print this application, only online applications will be accepted.
Personal Information
Surname/Last Name First Name


Second Name Third Name


Apt. No. Street Address

City/Town Province Postal Code



Telephone Number (Daytime) Telephone Number (Evening) Cell Phone Number
( ) ( ) ( ) -
E-mail Address

Social Insurance Number (SIN) Driver's License Number
- -


Present Occupation How long?


I can fluently read and write in
English French Other, please specify:



Education (Complete where applicable.)
Institution
No. of
Years
Attended
Year of
Graduation
(yyyy)
Diploma/Degree
High School

College

University

Technical
School

Other


Work Experience Provide details of all employment/business ventures, starting with your
present or most recent position.
Include any period of self-employment.
1. From
(yy/mm)
To
(yy/mm)
Company Name

City Type of Business

Position/Title
Annual
Salary
Reason for Leaving

$


2. From
(yy/mm)
To
(yy/mm)
Company Name

City Type of Business

Position/Title
Annual
Salary
Reason for Leaving

$


3. From
(yy/mm)
To
(yy/mm)
Company Name

City Type of Business

Position/Title
Annual
Salary
Reason for Leaving

$


May we contact your present employer?
yes no

Business References (Former employers or business contacts.)
1. Company Name

Contact Name Position/Title
Business Telephone
Number

( ) -

2. Company Name

Contact Name Position/Title
Business Telephone
Number

( ) -

3. Company Name

Contact Name Position/Title
Business Telephone
Number

( ) -


Business Location Preference
1. City Province 3. City Province






2. City Province 4. City Province







Other Information


Date Available
(yyyy/mm/dd)


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Is there anything that may adversely affect your ability to operate a successful retail
service business?

yes no



How much time will you devote to this business?

full-time part-time



How much time are you prepared to work? (Please check all that apply.)

more than 40 hours/week weekends



Annual income you expect to earn from your business

$



Have you ever been a Petro-Canada associate/agent?

no yes (Please
indicate when.)

Reason for leaving




Have you ever worked for a Petro-Canada associate/agent?

no yes (please
indicate when)



Name of associate, agent and/or territory manager?




Do you have any agreements or business relationships with competitors (petroleum
companies, convenience stores, car repair centres)

no yes (Please provide details below.)





Describe the successes in business ventures that you have experienced in the past that
make you feel you will succeed as a Petro-Canada associate, including any special
education, training or qualifications and any previous retail, administrative, supervisory or
other relevant experiences.



How did you learn about retailer opportunities at Petro-Canada?

Newspaper
Advertisement

Magazine
Advertisement

Internet
(Petro-Canada
Web site.)

Petro-Canada
Customer
Service
department

Referral by a Petro-Canada Retailer

Other


Retailer Name (if referred by
retailer)
Retailer Phone Number (if referred by retailer)


( ) -

Credit References
1. Bank Name

Branch Account Number Telephone Number

( ) -

2. Bank Name

Branch Account Number Telephone Number

( ) -

3. Bank Name

Branch Account Number Telephone Number

( ) -

Credit Card Account Numbers

VISA

MasterCard

Amex

Other Credit Cards / Loans

Confidential Financial Statement
Please enter a numerical figure if the amount is zero and do not use commas; text
characters such as "n/a" and commas will cause errors.

Assets
Cash in Bank
$
Stocks and Bonds
$
Real Estate - Home
$
Real Estate - Other
$
Personal Property
$
Other Assets
$

Total Assets
$


Liabilities
Accounts Payable
$
Bank Loans
$
Mortgages
$
Other Liabilities
$



Total Liabilities
$

Do you have any lawsuits pending, judgements or liens?
no yes (Please explain.)


Have you or any company with which you have been associated ever declared bankruptcy
or become insolvent?
no yes (Please explain.)


Have you ever declared personal bankruptcy?
no yes (Please explain.)


How much liquid cash investment can you
supply?
Sources of cash?
$


Sources of financial assistance (if applicable)

Family
Name

Other
Investments

Other Bank
Accounts

Will require
fincancial
Assistance
Assistance
from Petro-
Canada.

Other

Monthly Income
Requirements

Amount for Monthly Living

$
Amount for Monthly
Mortgage/Rent Payments
$
Amount for Monthly Loans
(auto/personal, etc.)
$

Total
$
Do you have any criminal convictions for
which pardon has not been granted that
would in any way relate to you fulfilling
your duties and responsibilities as a retail
associate of Petro-Canada?
no
yes (Please explain.)




By checking this box, I hereby certify this information to be true and complete and
consent to Petro-Canada's obtaining from, exchanging with or disclosing to other
credit grantors and recognized credit bureaus any and all information for the purposes
of ensuring the accuracy of this information, conducting ongoing credit investigations,
monitoring credit status and entering into and performing the Agreement, or
completing any of these at any time in the future should I be offered an agreement
with Petro-Canada. I authorize Petro-Canada, or its representatives, to at any time
verify the information provided and to request from me or obtain any other
information relevant to this application, including photo identification. This
information may be obtained by telephone or in writing from educational institutions,
my current or former employers, my personal references, other applicable parties, or
myself. I authorize validation of this information during the consideration of my
application to become an Associate, and if I am offered an agreement, for the duration
of the agreement. I understand that any false, omitted or misleading
statements/information provided may be grounds for rejection of my application or
immediate termination of any contract I have entered into with Petro-Canada without
notice. If I become a Petro-Canada Associate, I authorize Petro-Canada, or its
representatives, to release my information to the police and/or the applicable financial
institution(s) during any investigation of credit/debit card and/or suspected
criminal/fraudulent activities at or involving Petro-Canada retail sites. I acknowledge
and agree that submitting this application via the Internet has the same force and
effect as submitting a signed application in paper format.

Applicant Signature Date (yyyy/mm/dd)


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