Personal information
Gender:
Female
Male
Title of civility:
Dr.
Mr.
Ms.
Mrs.
First name:
Last Name:
Phone:
Cellular:
Email:
Social Security number:
Given name & surname, mother at birth:
Date of birth (Year / Month / Day):
Civil status:
Divorced
Married
Spouse of fact
Widower
Separate
Single
Correspondence language:
Francais
English
Address
Civic number:
Apartment: Yes: / No:
Name of the street:
City:
Zip Code:
Province:
Alberta
British Columbia
Prince Edward Island
Manitoba
New Brunswick
New Scotland
Nunavut
Ontario
Quebec
Saskatchewan
Newfoundland
Northwest Territories
Yukon
Home:
Owner with mortgage
Owner clear / without mortgage
Owner of a mobile home
Rent
With the parents
Housing on a reserve
Other
You are a tenant: Owner's name:
Owner's Phone:
Monthly payment:
How long have you been living at this address:
Years: Month:
Previous address (if less than two years)
Civic number:
Apartment: Yes: / No:
Name of the street:
City:
Zip Code:
Province:
Alberta
British Columbia
Prince Edward Island
Manitoba
New Brunswick
New Scotland
Nunavut
Ontario
Quebec
Saskatchewan
Newfoundland
Northwest Territories
Yukon
Home:
Owner with mortgage
Owner clear / without mortgage
Owner of a mobile home
Rent
With the parents
Housing on a reserve
Other
You are a tenant: Owner's name:
how long at this address:
Years: Month:
Owner
Mortgage balance (approximate, if applicable):
Market value of your home (if applicable):
Name of the creditor:
Information about your financial institution
Name of your financial institution:
Address of your financial institution: Civic number:
Name of the street:
City:
Zip Code:
Province:
Have you been bankrupt: Yes: / No:
Are you a member of Caisses Desjardins: Yes: / No:
Caisses Desjardins debit card number:
Current employment information
Type:
Unemployed
Home
Frame
Rent
leader
Administrative employee
Student
Worker
Production
Retirement
Service
Specialist
Self-employed worker
Specialized worker
Sale
Employer:
Status:
Retired
Seasonal (summer)
Seasonal (winter)
Part time (regular)
Occasional part-time
Full-time
Full time (Probation)
Self-employed worker
Retirement
Service
Specialist
Self-employed worker
Specialized worker
Sale
Profession:
Retired
Food / Agriculture
Insurance
Banking / Finance
Comunication
Construction
Law
Teaching / Research
Student
Armed Forces
Accommodation / Tourism
Manufacturing / Automotive Industry
Computer
General medicine
Specialty Medicine
Homemaker
Natural resources
Unemployed
Public Service
Transport
Sale / Retail
Are you the owner of the company: Yes: / Non.:
Supervisor's name:
Civic number:
Name of the street:
City:
Zip Code:
Province:
Phone:
Pay Period: Weekly / 2 weeks /monthly
How long has this job been:
Years: Months:
What is your income
Semaine: / Months: / Years:
Other source of income: (pension, annuity, etc.)
Previous job (if less than two years)
Previous Employer:
Position held:
Civic Number:
Name of the street:
City:
Zip Code:
Province:
Phone:
Personal identification
Your driving license #:
Expiry date of driving license:
Your health insurance card number:
Expiry date health insurance card:
Funding
Advance payment: Yes: / No:
Amount:
How many years do you want to have your financing:
Name of your representative at AQUA SERVICES:
What do you want to buy? (Describe s.v.p. as much as possible)
Comments
want to buy a boat through financing and I authorize Aqua Services to make a
apply for credit on my behalf, s.v.p. Check I ACCEPT and enter your initials below.
Consent
I, the undersigned and certify that the above information, which will be used to study my file,
are truthful. I hereby authorize any banking institution and / or the merchant
AQUA SERVICES as well as their employees, agents or representatives to conduct a survey of
solvency about me and to check my work history. I also accept that we use,
to the extent permitted by law, the information contained in my credit file and
use it as a history of my solvency. I admit that I was given the opportunity
to read this consent before signing.
I ACCEPT
 Initiale: