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Applicant's Personal Information

Full Legal Name

Home Address

City

Home Phone Number

Cell Number

Any Previous Dealings?

YesNo

How did you hear about us?

Any Prior Repossession?

YesNo

Birth Date(M/D/Y)

SIN

Prov

Postal Code

How Long

Monthly Payment

OwnRent

Email Address

Any Legal Suits?

YesNo

Have you ever declared bankruptcy?

YesNo


Transaction Details

Equipment Information

Make

Model

Year

Attachments

NewUsed$ Canadian$U.SLeaseLoan

Sale Price

$


Reason

AdditionalReplacements /If Replacing, What is being replaced?

What is the effect on the business? (Please Explain.)

General Corporate Information

Full Legal Business Name(Including "Operating AS")

ProprletorshipOtherCorporationPartnership

Corporate Address

City

Prov

Postal Code

Phone Number

Fax Number

Website

Financial Year End

Top 3 Clients

1. 2. 3.

% Of Business

1. 2. 3.

Total Years In Business

Number Of Employees

Fleet Size

Number Of Trucks

Number Of Trailers

Shareholder Contact Name

Ownership %

Shareholder Contact Name

Ownership %

Personal Net Worth

Assets Value

Residence

Cash On Hand

Personal Vehicles

Investments/RRSP

Other Assets

Total Assets

$
Liabilities Value

Mortgage

Loans

Credit Cards(s)

Other Liabilities

Total Liabilities

$

(Total Assets-Total Liabilities) NET WORTH

$

Business/Personal References

Refrence 1 Name

Relationship

Address

Telephone

Refrence 2 Name

Relationship

Address

Telephone

The Personal Information may be gathered and used by peel financial Inc, or its affiliates, its assignees and potential assignees, to provide products and to perform services as maybe requested by you. By assigning this document below, you have consented to these uses and disclosures.

Applicant's Signature

Date