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Personal information
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Mr.
Mrs.
Miss
Salutation
First Name
Middle Name
Last Name
SIN Number (Optional)
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Single
Married
Common Law
Separated
Divorced
Widowed
Marital Status
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0
1
2
3
4
5+
Dependants
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Country of Birth
Phone Number
Date of birth
Email
Address
Street Number
Street Name
Unit number
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Province
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City
Postal code
Labour data
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Employed
Self-employed
Unemployed
Employment Status
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Full time
Part time
Seasonal
Type of Employment
Employer / Business Name
Position
Gross Monthly Income (in CAD)
Work phone number
Work Address
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Bank (where the income is deposited)
Other Bank
Supervisor name and last name
Supervisor phone number
Legal Status in Canada
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Citizen
Permanent Resident
Work Permit
Study Permit
Refugee
Other
Legal Status in Canada
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< 1
1
2
3
4
5+
Total years in Canada
Loan details
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1,000.00
1,500.00
2,000.00
2,500.00
3,000.00
3,500.00
4,000.00
4,500.00
5,000.00
Requested amount
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12
18
24
Term (months)
Purpose of Loan
References
Reference 1
Name and Last Name
Relationship to you
Contact phone number
Reference 2
Name and Last Name
Relationship to you
Contact phone number
How did you hear about us?
Referral
Search engine (Google, etc)
Facebook Group
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Other
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