Online Application
Friday, May 09, 2008
E-Mail Address:
An email address is required to process this form!
*
Applicant Information:
*
First Name:
INIT:
*
Last Name:
*
Date of Birth:
/
/
(MM/DD/YYYY)
*
SIN:
-
-
Present Address:
*
Street:
*
City:
Prov:
*
Postal-Code:
How Long:
00
0
1
2
3
4
5
6
7
8
9
10
11
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16
17
18
19
20
>20
years
00
0
1
2
3
4
5
6
7
8
9
10
11
months
*
Home Phone:
-
-
Previous Address:
Street:
City:
Prov:
Postal-Code:
How Long:
00
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
>=20
years
00
0
1
2
3
4
5
6
7
8
9
10
11
months
Please Tell Us About Your Present Employment:
If you are retired, please note previous employer.
If you are self-employed, please note nature of business.
Employer:
Position:
Worked There:
00
0
1
2
3
4
5
6
7
8
9
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13
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20
>=20
years
00
0
1
2
3
4
5
6
7
8
9
10
11
months
Work Phone:
-
-
Please Provide Some Financial Information
Annual Household Income: $
.00
Please select the type(s) of bank account(s) you have:
Checking
Savings
Both
Neither
Monthly Rent or Mortgage: $
.00
Select Residence:
Rent
Own
Gov't
Other
Address of property to be mortgaged
Street:
City:
Prov:
Postal-Code:
Purchase price:
(Or if a re-finance) Approximate current value:
.00
Down Payment:
.00
Base Mortgage amount requested:
.00
Annual Taxes:
.00
Lot size:
Source of Downpayment:
Cash In Bank
Term Deposits
RRSP
Gift
Sale of Present Home
Inheritence
Other
Assets and Liabilities
Cash in Bank:
.00
Term Deposits:
.00
Mutual Funds:
.00
Stocks and Bonds:
.00
Value of Real estate presently
owned:
.00
(To be sold yes/no?)
Yes
No
Year and Make of Auto:
Value:
.00
Gift from relatives:
.00
Other:
Credit cards
Visa
MasterCard
American Express
Other
If other, please specify:
Approximate balances owing:
.00
Monthly payments:
.00
Mortgage Loans
Who with:
Approximate balance:
.00
Monthly payment:
.00
Personal Loans
Who with:
Approximate balance:
.00
Monthly payment:
.00
Other Loans
Who with:
Approximate balance:
.00
Monthly payment:
.00
Authorization
Authorization:
I/we authorize Lozinski Financial Services Ltd. to obtain such actual and investigative information regarding me/us from others as permitted by law. To furnish other credit grantors with credit bureau information and particulars of the credit application, subsequent credit experience if applicable, and to retain this application for its records.
PLEASE MAKE SURE YOU HAVE READ AND UNDERSTAND THE TERMS & CONDITIONS.
By submitting this form you acknowledge acceptance of terms and conditions of this application.
E-Mail:
jlozinski@bellnet.ca
Phone:
(613) 721-6843
FAX:
(613) 596-6445
Copyright© 1999. Lozinski
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