PERSONAL INFORMATION

Mr. Mrs. Miss. Ms.
Last Name: First Name:
Home Phone: Work Phone:
E-mail:

ADDRESS

Street:
City:
Province:
Postal Code:

EMPLOYMENT

Employer: Occupation:
Telephone No.: Yrs Employed: Monthly Income:


Previous Employer (Atleast 5 Years): Occupation:
Telephone No.: Yrs Employed: Monthly Income:

Other Income

Source: Monthly Income:
Source: Monthly Income:
Name & Address of spouse's employer.: Yrs Employed:
Monthly Income:

FINANCIAL INFORMATION

Name of bank or financial institution: Branch:
Account: Saving Chequing
Account Number:
Account Number:

Reason For the Loan

Purchase
Refinance
Credit Line
Home Improvement
Other, please describe:

Loan Amount

Loan amount desired is $

Type of Loan

30 yr fixed
15 yr fixed
30/5 yr fixed
30/7 yr fixed
Adjustable
Haven't decided
Other, please state