APPLICANT

NAME

BIRTHDATE

SIN

OWN/RENT

ADDRESS

CITY

POSTAL CODE

HOW LONG?

HOME TELEPHONE:

( )

BUSINESS TELEPHONE:

( )

EMPLOYER

OCCUPATION

HOW LONG?

ANNUAL INCOME

EMPLOYER IF LESS THAN 3 YEARS

EMPLOYER

OCCUPATION

HOW LONG?

ANNUAL INCOME

CO-APPLICANT

NAME

BIRTHDATE

SIN

OWN/RENT

ADDRESS

CITY

POSTAL CODE

HOW LONG?

HOME TELEPHONE:

( )

BUSINESS TELEPHONE:

( )

EMPLOYER

OCCUPATION

HOW LONG?

ANNUAL INCOME

EMPLOYER IF LESS THAN 3 YEARS

EMPLOYER

OCCUPATION

HOW LONG?

ANNUAL INCOME

NET WORTH STATEMENT

ASSETS

LIABILITIES

BALANCE

MTHLY PMT

CASH IN BANK

$

BANK LOANS

$

$

REAL ESTATE

$

MTGS

$

$

MF/STOCK/BOND

$

CREDIT CARDS

$

$

RRSP'S

$

CREDIT CARDS

$

$

AUTOMOBILE

$

OTHER LOANS

$

$

YR

MAKE

LINE OF CREDIT

$

$

OTHER ASSETS

$

TOTAL ASSETS

$

TOTAL LIABILITIES

$

PROPERTY INFORMATION

CLOSING DATE

MORTGAGE AMOUNT REQUIRED

ADDRESS OF PROPERTY

$

CITY

PROVINCE

POSTAL CODE

LEGAL DESCRIPTION

PURCHASE PRICE

$

DOWN PAYMENT

$

LAWYER INFORMATION:

NAME

TEL:

( )

REFERRED BY:

I CERTIFY THE INFORMATION AND THE ABOVE STATEMENT OF MY PROPERTY AND DEBTS IS TRUE. I DECLARE THAT NEITHER MY SPOUSE NOR ANY OTHER PERSON HAS ANY CLAIM IN OR TO THE ASSETS SHOWN ABOVE EXCEPT AS SET OUT HEREIN. THE WHOLE OF MY PROPERTY IS SHOWN AT FAIR VALUATION. I AM NOT BEING SUED AND THERE ARE NO EXECUTIONS AGAINST ME NEITHER DO I OWE ANYTHING TO ANY OTHER INSTITUTION EXCEPT AS REPORTED ABOVE.

CONSENT: I/WE AUTHORIZE, MAIN ST. MORTGAGE BROKERS LTD. TO OBTAIN SUCH FACTUAL AND INVESTIGATIVE INFORMATION REGARDING ME/US FROM OTHERS AS PERMITTED BY LAW.

APPLICANT SIGNATURE	CO-APPLICANT SIGNATURE
WITNESS	DATE