Financing Request First Name Last Name Social Security Number (not required but recommended) Phone Cellphone Date of birth Gender Marital status Email Correspondence language Current address (Address number, Street, City, Province, Postal Code) Since when do you live there Previous address if less than one year at current address (Address number, Street, City, Province, Postal Code) 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 (if applicable) 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) Previous work (if less than one year 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 one year at current work place) Previous work status (if less than one year 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 one year at current work place) Time worked at previous work place (if applicable) Address of previous work place if apllicable (Address number, Street, City, Province, Postal Code) Gross income (weekly, monthly or 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 (weekly, monthly or 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 Send
