An application for membership/renewal of membership is under consideration by the Atlantic Home Warranty (AHW). This is my authority to release the following information to AHW in connection with my application. This information is authorized on the express understanding and agreement that you will treat it as private and confidential and that neither the undersigned nor the bank shall be or become liable or responsible for or by reason of the giving of such information or its being inaccurate or incomplete.
To: Atlantic Home Warranty
15 Oland Crescent, Halifax, NS B3S 1C6
2. The above mentioned customer was directly liable to this Branch in respect to loans as follows (if none, so state):
Nature of collateral lodged by customer, I.E., Section 88, Section 86, general assignment of book debts, hypothecation of collections, assignment of specified accounts and payment under contracts, stocks and bonds, etc. (Give particulars of stocks, bonds or other negotiable securities lodged by (Customer) indicate if postponement held.
4. The above mentioned customer was contingently liable as endorser of notes and drawer of drafts discounted at this Branch and/or as guarantor in total amount of $ _ as below (if none, so state): (If the number of items herein is substantial the bank need report only the total)
5. Other direct or contingent liabilities, open letters of credit and acceptance thereunder, forward exchange contracts and relative collateral lodged by customer (if none, so state):
6. Securities held for account of customer, in addition to those reported in Section 2 and 5 (if none, so state), if for other than safekeeping, stat purpose. State whether bearer is registered and if registered, in whose name.