APPLICANT STATEMENT APPLICANT STATEMENT | First Name | Middle | Last | Date of Birth | |
| SIN | Home Phone | Present Address | ||
| City | Province | Postal Code | Time at Residence | |
| Own/Rent | Bank | Payment | Value | Balance |
| Previous Address | How Long | Single/Married/Divorced | ||
| Current Employer | Address | Phone # | How Long | |
| Occupation | Income | Other Income | Amount | |
| Previous Employer | How Long | Previous Occupation | ||
| Previous Vehicle Financed By | Payment | Amount Owing | ||
| Bank Information | Address | |||
A consumer/personal report containing credit, medical or personal information will be referred to in connection with this application and the undersigned consents to the preparation of such a report, and the undersigned further consents to Chrysler Financial Canada Ltd./Scott Campbell Dodge Ltd. obtaining credit, medical or personal information reports representing the undersigned from consumer reporting agencies. The undersigned hereby consents and acknowledges that Chrysler Financial Canada Ltd. and its successors or assigns shall have the right to disclose any information contained in a consumer/personal report of the undersigned to other credit grantors or consumer reporting agencies in it's own discretion or upon referral of the undersigned.
APPLICANT SIGNATURE - I, THE UNDERSIGNED, WARRANT THE TRUTH AND ACCURACY OF THE ABOVE INFORAMTION.
____________________________________________________ DATE __________________________