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Applicant's Information

First Name and Initial(s):

Last Name:

Date of Birth:

Home Number:

Work Number:

Cell Number:

Email:

Present Address:

Apartment #:

City:

Province/State:

Postal/Zip Code:

How Long At This Address?
Years Months

Own/Rent/Parents?

Monthly Rent or Mortgage:

Mortgage Lender:

Social Insurance Number (Optional):

Driver's License Number + Province (Optional in Quebec):

Occupation:

Present Employer (Company Name):

Contact Name:

Employer's Phone Number:

Length of Employment:

Employment Status:

Gross Monthly Income:
$

Other Income (Specify):
$

If Self Employed, State Name of Source of Income / Accountant:

Accountant's Phone Number:

Please Provide Two Personal References:
#1 First Name:

#1 Last Name:

#1 Phone Number:

#2 First Name:

#2 Last Name:

#2 Phone Number:

Terms and Conditions

I/we understand that the above information (the "Collected Information") is being collected for the purpose of obtaining credit from Medicard, a division of iFinance Canada Inc. ("iFinance"), and is warranted to be true and complete. I/we hereby authorize and consent to the colection of the Collected INformation and to the making by iFinance, its successors and assigns of whatever credit investigations and/or employment and income confirmations iFinance or its successors and assigns may deem appropriate from time to time, and to the disclosure, sharing or exchange of the Collected Infromation and any report or information based thereon for these purposes with credit reporting agencies, and amongst iFinance, its successors and assigns or any company with whom I/we have or propose to have a financial relationship.

By checking off this box, I/we accept these terms.

Amount of Financing Required:
$

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