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PERSONAL APPLICANT INFORMATION
First Name :
 Middle Name :
 Last Name:
SIN# :
 Date of Birth :
 Home phone #
Address :
 City :
Province :
 Postal code :

Residence Type(s) :
Own : Rent : Other :

At Residence Since :
Year : Month:

PREVIOUS ADDRESS INFORMATION (IF LESS THAN ONE YEAR)

Previous Address:
 City:
 Province:
 Postal Code :
Residence Type(s) :
Own : Rent : Other :

At Residence Since :
Year : Month:

PERSONAL CREDIT INFORMATION

Employer Name :
 Occupation :
Employment Start Date:

Business Phone # :

Annual Employment
Income:
$ 		Other Annual
Income:
$ 		Describe Other
Income
 Credit Cards :
Visa : M.C. : Amex :
Credit Card Number :
Bankruptcy : (s)
Yes : No : 		Monthly Obligation :
$

Monthly Residence Costs :
$

Mortgage Balance :
$ 		Purchase Price :
$

PREVIOUS EMPLOYMENT INFORMATION (IF LESS THAN ONE YEAR)

Employer Name :
 Occupation :
Employment Start Date :
Year : Month :

Annual Employment Income :
$


Please describe the item you wish to purchase

Email address for follow up contact :

Privacy Policy and Consent

I consent to the Yamaha dealer collecting personal information set out above and to disclose it to GHR Systems Inc. and to HSBC Retail Services Limited. I authorize GHR Systems Inc. and HSBC Retail Services Limited to obtain factual and investigative information regarding myself from others as permitted by law and to furnish other credit grantors and credit reporting agencies with particulars of this credit application and subsequent credit experience.


Signature (applicant) Date
Signature (co-applicant) Date

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