Full name (Last, First)

Social Insurance Number

Driver’s License #

Birthday (MM/DD/YYYY)

Current Address

E-mail Address

Verified Address

How long at this address?

Phone Number

Mobile Phone Number

Employment Information

Company

Employer name and address

Phone

Length of Employment

Hourly / Salary

Your Position

Supervisor’s name and phone

Computerized Pay Stub?

Yes No

Direct Deposit?

Yes No

Date of Pay

Weekly/ Bi-weekly/ Monthly

Banking Information

Name of Financial Institution

Address / Main Intersection

Personal Chequing Account?

Yes No

Is this a joint account?

Yes No With whom

Do you have a pre-printed cheques?

Yes No

Bankruptcy

Yes No

Garnishments

Yes No

NSFs In previous 2 months?

Yes No

Have you used payday loans before?

Yes No

If yes, which one(s)?

Do you have any current loans?

Yes No

Amount requested

$

How did you hear about us?

Date

Signature