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Personal Information

Applicant’s Name    
Address: Postal Code:
Home Phone: Work Phone:
Fax: Email Address:
Social Insurance Number: Birthdate:
Employer Address:
Employer Phone: Employer Fax:
Employer Email: # of years employed
Spouse’s name: Spouse’s employer
Number of Dependents: Your Annual Income:
Spouse’s Income: Other Income:
Years at Present Address:    
Do you ? Monthly Fee:
Landlord’s name: Landord's Phone:
Name of Bank: Branch:
Account Type: Account Number:
Have you ever borrowed before? Where from?
Do you have any loans or credit card balances outstanding?
If yes please give details and amounts owing:




Market Value







Cash, Bonds, Securities, RRSPs etc.




Net Worth: Income + Assets – Liabilities (amount owed) =

I certify that all the information in this statement is true and complete and understand that it will be used by Kitikmeot Community Futures Inc. (KCFI) to determine my creditworthiness. I agree that the KCFI may also give to, receive from and share with others, including credit bureaux, and persons and organizations with whom I have or may have financial dealings, credit and other information about me.

Applicant Signature
(please type full name)

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