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APPLICANT'S PERSONAL INFORMATION

Last name
 First name
 Middle Initial
Address
 Postal Code
City
 Province
 Own
Rent
Other
Phone
 Cell
How long at address
 No. of dependant(s)
Landlord / Mortage Holder Name
 Landlord / Mortage Holder Phone
Date of Birth (mm/dd/yy)
 Social Insurance Number
 Drivers License No
Previous Address (if < 1 yrs at present)
 How long at address

EMPLOYMENT

Present Employer
 Nature of Business
Address
 Phone
 Gross Monthly Income
How long with present employer
 Current Position
Other Income
Former Employer
 Phone
Occupation
 How long with previous employer

SPOUSE / CO-APPLICANT

Last name
 First name
 Middle initial(s)
Date of birth (mm/dd/yy)
 Social Insurance Number
Present Employer
 Phone
 Gross Monthly Income
How long with present employer
 Current Position

PERSONAL STATEMENT

Assets

Value

Real Estate
Autos
Cash
Other
Other
Total

Liabilities

Amount Owing

Monthly Payment

Mortgage Holder & Phone No.
Rent
Credit Cards
Loans
Other
Real Estate
Total
Name of Bank
 Phone
 Contact
Address/Branch No
 Account No.
Credit Cards
VisaAmexMastercardOther

RELATIVES, CLOSE FRIENDS OR ASSOCIATES

(required)
Name
 Address
 Phone
Name
 Address
 Phone
Name
 Address
 Phone

LEASE REQUEST

Year
 Make
 Model
NewUsed KM's or Length
 ID Number or Serial Number
Purchase Price
 Down Payment
 Monthly Payment Target
Preferred Term
 LeaseFinance

The undersigned certifies the above information to be true and correct. By signing below, I consent to Dominion For Finance Inc. (herein referred to as Dominion) and its subsidiaries and affiliates obtaining from any credit reporting agency or credit grantor, such information as it may require at any time in connection with the credit hereby applied for, and consent to the disclosure at any time of any information concerning the undersigned to any credit reporting agency or to any credit grantor with whom the undersigned has financial relations.

Dominion and its subsidiaries and affiliates may use my personal information (including credit and other financially-related information) and disclose it to each other when it is necessary in order to serve a customer, to meet legal and regulatory requirements, and for internal audit, statistical and record keeping purposes. Dominion may collect and use my personal information with subsidiaries and affiliates in order to identify and inform me of products and services that they offer.

Although not required by law, Dominion and its subsidiaries and affiliates may collect, use and share my SIN to help ensure accuracy on credit checks and for statistical and record-keeping purposes.

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