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General
Purchaser or Firm Name	Choose One	Corporation Individual Partnership	Date of Birth	Social Insurance (Optional)		Res. Phone
Purchaser Address City/Province					Years	Bus. Phone
Previous Address City/Province					Years	Bus. Phone
Business Address City/Province				Source of other Income		Other Mo Income$
Home of Principal	Choose One		Mortgage or Landlord Name & Address		Market value	Mo Pmt/Rent Pmt
	Own Buying Renting	Mobile Home Live w/Relatives

Credit

Bank Name and Address

Choose One

Chequing

Saving

Borrowing

Chequing Balance

Saving Balance

Amount Owing

Secured Creditor Name

Address

Phone

Have you ever had equipment repossessed?

Yes

By Whom

When

Purchaser ever filed Bankrupcy?

Yes

Where

When

Terms and Conditions:

I acknowledge and agree that, upon receipt of a duly signed copy of this purchaser's statement ("Statement"), The Lender,  ("The Lender") and the Dealer shall be entitled and authorized to establish a file on me containing personal information.

The object of the file shall be to allow The Lender and it's worldwide affiliates and assignees (1) to evaluate my credit and solvency; (2) to make a decision with regard to the Statement and the possible execution of an agreement, including a contract for lease or financing of a purchase of a motor vehicle; (3) to monitor, record and determine during the term of such a contract my compliance with all or part of the obligations contained therein; (4) to answer any questions I might have with respect to the Statement, any contract I may enter into and the file in general; (5) to record, manage, evaluate and collect, if applicable, any amount owing by me to The Lender; (6) to develop and implement customer programs; (7) to maintain and use the information as a credit history;  and (8) to meet legal and regulatory requirements.

To achieve the object of the file, I understand that the personal information contained in my file shall be made available only to the employees, representative and agents of The Lender and its worldwide affiliates and assignees who require it in the course of the performance of their duties or mandates. The personal  information in my file will be used to make any relevant decisions in order to achieve the object of the file.

The file relating to me shall be kept at my The Lender Zone office (the address of which can be supplies by the Dealer.) The Lender shall inform me in writing if my file is moved to a new location. I understand that I shall have the right: (1) to obtain access to the personal information in my file and (2) to rectify any personal information in my file which is inaccurate, incomplete, ambiguous or out-of-date. I shall be entitled to exercise either one of these rights by addressing a written request for access or rectification to my The Lender Zone office in care of the Access to the Information Manager.

I authorize The Lender and the Dealer to collect the necessary personal information concerning me to fulfill the object  of the file, from third persons, including credit agencies, information and collection agencies, credit reporting bureaus, financial institutions, insurance companies, insurance brokers, my past, present and future employers, creditors and landlords, motor vehicle dealers, government agencies, my spouse or any other person who has or will have information related to my credit history and my solvency, my whereabouts or the whereabouts or condition of any property that is or has been owned, held or leased by me. I specifically consent to the release and disclosure of personal information by such persons to The Lender and the Dealer. 
If I request a credit life or disability insurance, I expressly authorize any doctor, physician, a member of a professional corporation in the health sector, health establishment, clinic, hospital, or medical information office or a health information custodian to disclose, release and communicate to The Lender personal information, including personal health information, concerning me and expressly authorize The Lender to disclose personal information to them.

I expressly authorize The Lender and the Dealer to disclose personal information concerning me to each other, to any of their worldwide affiliates and assignees, to other third persons including advertising and marketing agencies dealing with The Lender for the development and implementation of customer programs, to credit agencies, to information and collection agencies, to credit reporting bureaus, to financial institutions, to insurance companies, to insurance brokers, to vehicle manufacturers, to motor vehicles dealers, to auction houses, to my creditors, to persons to whom I have applied for credit, to assignees and agents of such third parties, and to any other person to whom The Lender or the Dealer deem it necessary to further my interest or to fulfill the object of the file.

I specifically consent to the use by The Lender of my Social Insurance Number, if supplied, for the purpose of recording, identifying and retrieving my personal information. Supplying Social Insurance Number helps The Lender distinguish me from other with similar information and accelerates the process of achieving the object of the file. 
I have read the Statement and the consent respecting the collection, use, release, disclosure, communication and holding of personal information concerning me. I understand the signification and the necessity of giving such a consent which is given voluntarily without any coercion and which will be valid for so long as it is needed in order to achieve the object of the file. I acknowledge that the Dealer or its representatives have no authority to waive or modify any question in the Statement, or bind The Lender by making a promise or representation or by giving information without the written consent of The Lender.

I accept that a photocopy of the Statement and the consent or a facsimile of same shall be considered as valid as the original. 
I declare and warrant that the information that I have provided above is true, accurate and complete and that it is not false or misleading in any way. I further declare and warrant that a bankruptcy proceeding is neither presently in progress nor anticipated and acknowledge receiving a copy of this Statement. IN THE EVENT OF ANY MATERIAL ADVERSE CHANGE IN MY FINANCIAL POSTION, I AGREE TO NOTIFY The Lender in writing.

I acknowledge that the Statement and the Consent were drafted in the English language in accordance with my request. Je déclare avoir exigé que cette demande et ce consentement soient rédigés et complétés en langue anglaise.
I acknowledge that a consumer/personal report containing credit, medical or personal information will be referred to in connection with the application. I consent to the preparation of such a report to The Lender and the dealer obtaining such a report from credit bureaus/consumer reporting agencies.

I agree

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