Date (MM/DD/YY) Representative Please select…LauraRichardChelsey Clear Form
Name of Lessee (Include Middle Name) Street Address Unit / Apt City Province Please select…ABBCMBNBNLNTNSNUONPEQCSKYT Postal Code Phone Email Date of Birth (MM/DD/YY) Social Insurance Number Marital Status Please select…SingleMarriedCommon-LawSeparatedDivorcedWidowed Driver’s License Number Driver’s License Expiry (MM/DD/YY) Present Insurance Company/Broker Insurance Expiry (MM/DD/YY)
Time at Address Home Ownership Status Please select…OwnRentLive with FamilyOther Monthly Rent / Mortgage Payment ($) Name & Address of Landlord or Mortgage Co. Market Value ($) Mortgage Amount ($)
Previous Address (Street, City, Province) Time at Previous Address
Name & Address of Current Employer Time on Job Employer Phone Approx. Monthly Income “A” ($) Name & Address of Previous Employer Time on Previous Job Previous Monthly Income ($) Source(s) of Other Income Other Monthly Income “B” ($)
Spouse’s Employer Spouse’s Employer Phone Spouse’s Monthly Income “C” ($) Spouse’s Time on Job Combined Monthly Income “A + B + C” ($)
Bank / Credit Union Branch Address and City Bank Phone Account Number Active Credit Cards
You, the undersigned, hereby declare that all the information provided herin is to the best of your knowledge true, complete and correct and you understand that it may be used to determine your credit worthiness. In order to assess your ability to meet your financial obligations, you authorize Nisco National Leasing div of HVL Ltd. and its agents or assigns:
1) to request and obtain personal information about you on an ongoing basis from credit bureaus from information they previously collected about you in order to assess your credit history;
2) to exchange your personal information on an ongoing basis with credit bureaus in order to protect you, ensure the completeness of the information and maintain the integrity of the credit granting system;
3) to co-operate with local, provincial, and national authorities in the investigation of unlawful or improper activities in order to protect you and us from fraudulent transactions; and
4) disclose your personal information where necessary to protect your interests, and ours.
I agree to the terms above. Name of Lessee (Include Middle Name) Applicant Signature Type Draw Use mouse or finger to sign Clear Date (MM/DD/YY) Clear Form Submit Print / Save PDF
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