Repair Finance Application
Personal Information
Full Legal Name
- -
Date of Birth
Driver's License Number
Home Address
Postal Code
Home Phone Number
( )
Years at Address
Months at Address
Previous Home Address
Previous City
Previous Province
Previous Postal Code
Previous Home Phone Number
( )
Years at Previous Address
Months at Previous Address
Own Jointly?
Value of Home (approx.)
Mortgage Balance
Mortgage / Rent Payment
Employer Name
Occupation / Job Title
Employer Phone Number
( )
Employer Address
Employer City
Employer Province
Employer Postal Code
Years with Employer
Months with Employer
Previous Employer Name
Previous Occupation / Job Title
Previous Employer Phone Number
( )
Previous Employer Address
Previous Employer City
Previous Employer Province
Previous Employer Postal Code
Years with Previous Employer
Months with Previous Employer
Yearly Salary
Other Income Sources
Have you ever declared bankruptcy?
Add Co-Applicant?

Equipment Details
Supplier Name
Equipment Cost
Type of Equipment (include make & model)
Contract Term

Additional Notes

I/We certify that all the information in this application is true and complete. I/We acknowledge that all the personal information gathered maybe used by IndCom Leasing Inc., its funders, agents and assigns, to assess my credit worthiness, provide products, and administrate the contract and to perfrom services as may be requested by me. IndCom Leasing 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. IndCom Leasing Inc. may also disclose my personal information where they are required or premitted 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 the IndCom Leasing Inc., Chief Privacy Officer. By executing this document below, I have consented to these uses and disclosures.