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Financing Request
First Name
Last Name
Social Security Number (not required but recommended)
Phone
Cellphone
Date of birth
Gender
Marital status
Single
Separated
Widow/Widower
Common law
Married
Divorced
Email
Correspondence language
Current address (Address number, Street, City, Province, Postal Code)
Since when do you live there
Previous address if less than 2 years at current address (Address number, Street, City, Province, Postal Code)
How long have you stayed at your previous address
Property / Mortgage Details (please select)
Please select
Property with mortgage
Property without mortgage
Mobile home owner
Rent
Living with your parents
Housing on a reserve
Other
Market value of your property (if applicable)
Mortgage balance (if applicable)
Mortgage holder or landlord name
Monthly payment (if applicable)
Current Work
Please select
At home
Executive
Labourer
Management
Office staff
Production
Professional
Retired
Sales
Self-Employed
Service
Student
Trades
Unemployed
Other
Employer
Work status
Please select
Retirement
Seasonal
Regular part-time
Occasional part-time
Full-time
Full time (probation)
Self-employed
Work occupation
Since when do you work there
Work address (Address number, Street, City, Province, Postal Code)
Work phone number
Previous work (if less than 2 years at current work place)
Please select
At home
Executive
Labourer
Management
Office staff
Production
Professional
Retired
Sales
Self-Employed
Service
Student
Trades
Unemployed
Other
Previous employer (if less than 2 years at current work place)
Previous work status (if less than 2 years at current work place)
Please select
Retirement
Seasonal
Regular part-time
Occasional part-time
Full-time
Full time (probation)
Self-employed
Previous work occupation (if less than 2 years at current work place)
Time worked at previous work place (if applicable)
Address of previous work place if applicable (Address number, Street, City, Province, Postal Code)
Work phone number of previous place if applicable
Gross income
Specify weekly, monthly or yearly
Weekly
Monthly
Yearly
Other type of income
Please select
Car allowance
Child support / alimony
Disability payments
Investment income
Pensions
Rental income
Worker compensation
Other
Other income amount
Specify weekly, monthly or yearly
Weekly
Monthly
Yearly
Financing Term
Please select
12 Months
18 Months
24 Months
36 Months
48 Months
60 Months
Payments frequency
Monthly
Weekly
Bi-Weekly
Please include a copy of your driver's license
Personal information
I authorize Talaria / Ebikezilla to disclose my personal informations with the bank in order to submit my financing request
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