Email Address: ……………………………………… CIF #: ………………………………

Mother’s Maiden Name: …………………………… A/C #: ………………………………

Spouse: Salary Assignment: ……………….

Name: …………………………………………………
Job: …………………………………………………… Can it be assigned to FC? (YES/NO)
Employer: ……………………………………………..

Reference:
Name: ………………………………………………… Statutory Deductions: ____________
Contact Number: ……………………………………... Hlth Plan/Insurance: ____________
Address: ……………………………………………… Pension: ____________
………………………………………………………
… Utilities: ____________
Job: …………………………………………………… Monthly Living Exp: ____________
Employer: ……………………………………………..

Reference: Customer for ______ years

Name: ………………………………………………… Loans Repaid (excluding ref.): _____
Contact Number: ……………………………………... Loans Repaid (ref.): _____
Address: ………………………………………………
………………………………………………………
…
Job: ……………………………………………………
Employer: ……………………………………………..

Property:
Reg. Owner: …………………………………………..
Property Description: …………………………………
………………………………………………………
…
………………………………………………………
…
Year Purchased: ..……………………………………..
Purchase Price: ………………………………………..
Present Value: ………………………………………...
Fire Insurance: (YES/NO)