Broke on Payday - Application

APPLICATION FORM

This application is designed to be completed by any consumer applicant(s) who is requesting a financial product / service through ZERO BALANCE FINANCIAL, but provided by a Canadian Financial Institution. Applicants should complete this form as applicable.

I. TYPE OF PRODUCT / SERVICE REQUIRED
Mortgage Credit Score Debt Collection	Loan Auto Foreclosure	Business Financing Employment Legal	Do you have Notice of Assessments for Taxes: 2004 Yes No 2005 Yes No 2006 Yes No
Are you a Property Owner? Yes No	Are you employed? Yes No	Are you Self Employed? Yes No	Are you a past bankrupt? Yes No

II. PURPOSE OF CREDIT FACILITY

Purchase House 2nd Mortgage Education Travel Family Emergency Business Other (explain):

Briefly explain your present financial situation:

Are you presently in collections or being sued? Yes No (explain)

III. BORROWER INFORMATION
Applicant * required fields
Applicants Name* (include Jr. or Sr. if applicable)
Social Insurance Number	Telephone *(incl. area code)	Date of Birth*
Married Unmarried (include single divorced, widowed) Separated		Dependents Number: Ages:

Cell Phone	E mail Address *
*Personal Address (The following must be Completed):**
Number, Street, city, Province, Postal Code
Own Rent No. Yrs.

IV. EMPLOYMENT INFORMATION
Applicant
Name and Address of Employer Self Employed	Years on this job
	Monthly Income: $
Position/Title/Type of Business	Business Phone

If employed in current position for less than two years or if currently employed in more than one position, complete the following:
Name and Address of Employer Self Employed	Dates(from-to)
	Monthly Income $
Position/Title/Type of Business	Business Phone

Certification: I certify that the information provide in this application is true and correct as of the date set forth opposite my Initials on this application and acknowledge my understanding that any intentional or negligent misrepresentation(s) of the information contained in this application may result in civil liability and/or criminal penalties in accordance with Canadian Laws. I authorize Zero Balance Financial or it agents to obtain credit report(s) and understand that entering our names below and submission via internet is legally the same as a personal signature.

*Applicant Signature (Initials)

Date

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