AQUA SERVICES - LE LEADER DU NAUTISME

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Personal information
Gender:
Title of civility:
First name:
Last Name:
Phone:
Cellular:
Email:
Social Security number:
Given name & surname, mother at birth:
Date of birth (Year / Month / Day):
Civil status:
Correspondence language:
Address
Civic number:
Apartment:	Yes: / No:
Name of the street:
City:
Zip Code:
Province:
Home:
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:
Home:
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:
Employer:
Status:
Profession:
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:

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