YOUR CURRENT RESIDENCE
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
YOUR CURRENT EMPLOYMENT
Employment Status
*
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Full Time
Part Time
Self Employed
Homemaker
Student
Retired
Contract
Seasonal
Temporary
Unemployed with Income
Unemployed without Income
Occupation/Job Title
*
Employer Name
*
Employer Phone Number
*
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Employer Email Address
Employer Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Years With Employer
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0 Years
1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years
10+ Years
Months With Employer
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1 Month
2 Months
3 Months
4 Months
5 Months
6 Months
7 Months
8 Months
9 Months
10 Months
11 Months
Gross Monthly Salary
*
Other Income
YOUR PREVIOUS EMPLOYMENT
Since You've Worked less than 2 Years at your previous job
Employment Status
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Please Select
Full Time
Part Time
Self Employed
Homemaker
Student
Retired
Contract
Seasonal
Temporary
Unemployed with Income
Unemployed without Income
Occupation/Job Title
*
Employer Name
*
Employer Phone Number
*
Please enter a valid phone number.
Employer Email Address
Previous Employer Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Years With Employer
*
Please Select
0 Years
1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years
10+ Years
Months With Employer
Please Select
1 Month
2 Months
3 Months
4 Months
5 Months
6 Months
7 Months
8 Months
9 Months
10 Months
11 Months
Gross Monthly Salary
*
PERSONAL INFORMATION
PLEASE RE-ENTER YOUR PERSONAL INFORMATION
Title
*
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Mr
Mrs
Miss
Ms
First Name
*
Middle Name
*
Last Name
*
Marital Status
*
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Married
Divorced
Single
Separated
Common Law
Widower
Birth Date
*
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Month
-
Day
Year
Date
Your Phone Number
*
Please enter a valid phone number.
Your Email Address
example@example.com
Drivers License Number (ID)
Social Insurance Number (SIN)
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*Upload* - Proof of Income (Paystubs, or Bank Statements)
UPLOAD PROOF OF INCOME
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Certification
I/We certify that all the information in this application is true and complete. I/We acknowledge that all the personal information gathered may be used by Autoplex Alberta Inc. its funders, agents and assigns, to assess my credit worthiness, provide products, and administer the contract and to perform services as may be requested by me. Autoplex Alberta Inc. may also disclose my personal information to third parties such as but not limited to credit reporting agencies, financial institutions, financing companies, securitization organizations and my insurance agent or company. Autoplex Alberta Inc. may also disclose my personal information where they are required or permitted by law to do so. Subject to legal and contractual requirements, you may refuse or withdraw your consent to certain of the identified purposes at any time by contacting Autoplex Alberta Inc. By executing this document below, I have consented to these uses and disclosures. My submission to this form is an acceptance to authorize the obtaining and release of information as it pertains to processing this application.
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