All fields are required except where noted. Financing is approved OAC (on approved credit).
Mr. Mrs. Miss Ms. Dr.
Single Married Separated Divorced Common Law
Number of Dependents
Date of Birth
Social Insurance Number
Driver's License Number
Driver's License Expiry
Own Rent Living with family
Mortgage/Rent (per month)
Mortgage Balance (if applicable)
Mortgage Holder (if applicable)
Time at Residence
Have you ever declared bankruptcy?
Self-Employed Full Time Part Time Seasonal Contract Retired
Time with Employer
Other Income (if applicble)
I hereby consent that by submitting this application, I am giving Francis L Enterprises, Inc. permission to check my credit.