First Name:    Last Name:

Home Phone:     Cell Phone:

E-mail:   SIN No: 

Date of Birth: -- mm/dd/yy     Sex: Male Female

Home Phone is in my name?    Yes No

Home Address:

City:     Province: Ontario        Postal Code:

This is my primary home since, 3 months or less 4 months to 6 months 7 months to an year More than 1 year More than 2 years More than 3 years More than 4 years More than 5 years More than 10 years More than 20 years

Work related Information:

Do you have a full time job? Yes No  

How long have you been employed at your current job? 3 months or less 4 months to 6 months 7 months to an year More than 1 year More than 2 years More than 3 years More than 4 years More than 5 years More than 10 years More than 15 years More than 20 years

How often do you get paid? Weekly Every 2 weeks Twice a month Monthly

Your last pay date?  -- mm/dd/yy 

Your next pay date? -- mm/dd/yy

What is your after tax pay, your last pay period (in Dollars)?

Employer Name: Main Phone:

Work Location Address:

City:     Province: Ontario        Postal Code:

Supervisor's Name (for our records): Phone:

Your direct phone or extension number (if any)?

What days and shifts do you work?:

Banking Information:

Is your pay direct deposited into your bank account? Yes No

How long have you had the above bank account? 3 months or less 4 months to 6 months 7 months to an year more than a year More than 2 years more than 3 years More than 4 years more than 5 years more than 10 years

In last 3 months how many NSF/ Returned checks do you have? None One Two Three Four Five Five or more Ten or more

In last 3 months how many stop payments do you have: None Four One Two Three Five or more Ten or more

Have you filed for bankruptcy Yes No

If Yes when was the last time you filed? -mm/yy

Have you filed for a Consumer Proposal or Credit Counselling? Yes No

If Yes, when was the Consumer Proposal or Credit Counselling filed? -mm/yy

Has your pay been garnished in last 3 years? Yes No 

If Yes when was the last time your pay was garnished? -mm/yy

Reference 1:

Name:    Relationship:

Phone: (preferably member of immediate family)

Reference 2:

Name:    Relationship:

Phone: (preferably coworker or close friend)

Other Information:

How did you find out about us? From Bell Yellow Pages I have seen signs or posters From Telus Super Pages From a paid daily news paper From a free daily news paper From a friend From a TV ad Google Driving by Other Search Engine Other

Additional Information:

I understand that Totally Cash Inc. is relying on this disclosure statement to determine my eligibility for a loan.

I do not intend to file bankruptcy or make a creditors proposal before this loan is repaid. Should I make a creditors proposal or file bankruptcy until this loan remains unpaid in whole or part, I will direct my trustee to honor the wage assignment that I have signed on this date and make payment directly to Totally Cash Inc.

I agree to allow Totally Cash Inc. to obtain and share my personal records and credit information regarding this loan, with any third party, including the people working in Payroll Dept. or Human Resources Dept at my employment.

I warrant that the information contained in this application is true, accurate and complete.

I hereby give permission to verify the above information for a credit decision based on the verified information.