APPLICATION STATEMENT

APPLICATION STATEMENT

Dealership Name: _______________________________________________________________________________

RETAIL

LEASE

OTHER

CHECK ONE APPLICABLE BOX (PRIMARY APPLICANT AND JOINT APPLICANTS MUST COMPLETE SEPARATE FORMS): Primary Applicant Joint Applicant

If Joint Applicant, Relationship to Applicant:

Application is for joint credit with primary applicant or as a guarantor

S ? Spouse

F ? Family

Primary applicant is relying on you for income for alimony, child support, or separate maintenance or on your income or assets as the basis for repayment of the credit requested

O ? Other

Last Name

First Name

Middle Initial

J

Jr. No. of Dep. Date of Birth (mm/dd/yyyy)

S

Sr.

Present Address (Number and Street)

A

P

P L Phone in Applicant's Home?

1 Yes 2 No

I

C 1 Own Home Outright

2 Buying Home

A Social Insurance Number (Optional) N

T

E-Mail

Home

Address

City Area Code and Phone Number

3 Living with Relatives Driver's License Number

4 Leasing / Renting

Work

Province

Select...

Postal Code

Lived There _____Yrs. _____Mos.

5 Own / Buying Mobile Home

Province

Select...

Name and Address of Landlord or Mortgage Holder Previous Address (Street, City, Province and Postal Code) (if less than 2 years at present address)

Rent or Mortgage Pmt. $_________________ Lived There _____Yrs. _____Mos.

Level of Education (Age Under 27 Only)

1

University (graduate) 2

College / CEGEP (diploma) 3

Special Training 4

Some College

High School grad? 5

Yes 6

No

E Current Employer Name

M

P Applicant's Occupation L

O

Y Time on Job

* Alimony, child support or separate maintenance income

M E _____Yrs. _____Mos.

need not to be revealed if you do not wish to have it considered as a basis for repaying this obligation.

N Previous Employer's Name (if less than 5 years at current employer)

T

City Work ? Area Code and Phone Number * Source of Other Income

City

Province

Select...

Gross Salary $________________

W ? Weekly M ? Monthly

Y ? Yearly

* Other Income $________________

W ? Weekly M ? Monthly

Y ? Yearly

Province

Select...

Time on previous job _______ Yrs.

Name of Bank

Account #

1 Chequing & Savings 3 Savings Only

Address of Bank

2 Chequing Only

4 No Account

Have You Ever Had a Car or Other Merchandise Repossessed?

No

Yes If Yes, When? Month: _S__e_le__c_t._._.__________ Year: ______

Have you Ever Filed Bankruptcy?

No

Yes If Yes, When? Month: _S__e_le__c_t._._._________ Year: ______

C R

Is Applicant Obligated to Make Alimony, Child Support or Separate Maintenance Payments?

E

D

Creditor's Name and City/Province

Account Number

I T

(Current / Previous Cars Financed by or Leased Through) 1

No

Yes If Yes, Amount to Be Paid per Month is $________________

Date Opened (mm/dd/yyyy)

High Credit

Monthly Pmt Amount

Unpaid Date of Last Pmt

Balance

(mm/dd/yyyy)

D A 2

T

(Other)

A 3

Personal References 1 2 3

Area Code and Phone Number Relationship Area Code and Phone Number Relationship Area Code and Phone Number Relationship

FC-27141 (04/2013) Previous editions may NOT be used.

Continued on next page.

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CONSENT REPECTING PERSONAL INFORMATION

This following terms form part of this Application Statement.

A. CREDIT REVIEW

You agree to the dealer and Ford Credit Canada Limited (Ford Credit) / Ford Credit Canada Leasing* (FCCL) (including third parties acting for them or on their behalf, the "Dealer", "Ford Credit" and "FCCL", respectively), obtaining a credit report or other credit information from any credit reporting agency, credit bureau, or credit grantor (which may require disclosure of certain information in this Application), and exchanging, holding and using such information in order to evaluate your credit and document the decision on your application, including for related audit, quality assurance (including call monitoring) and risk management purposes.

If your application is not approved, Ford Credit or FCCL will retain the information for one year in order to allow you to access it.

B. If your application is approved and you enter into a finance or lease contract with Ford Credit or FCCL, you also agree to:

ADMINISTERING YOUR ACCOUNT

(i) the Dealer (or in limited circumstances another Dealer who becomes responsible for servicing your finance or lease contract) and Ford Credit or FCCL exchanging, holding and using information relating to your finance or lease contract in order to administer the contract including related audit, quality assurance (including call monitoring) and risk management purposes;

UPDATING YOUR CREDIT INFORMATION

(ii) Ford Credit or FCCL holding, using and disclosing to one another and any credit reporting agency or credit bureau, and the credit reporting agency or credit bureau collecting, holding and using, information in this Application or relating to your finance or lease payments or any other amounts due under your finance or lease contract in order to maintain up-to-date credit information about you;

CONTACTING YOU

(iii) any third party disclosing to Ford Credit or FCCL, and Ford Credit or FCCL collecting, holding and using, your contact information, where Ford Credit or FCCL needs to contact you about your finance or lease contract or vehicle and is unable to contact you at the last address or telephone number provided by you;

TRANSFER OF YOUR ACCOUNT

(iv) Ford Credit or FCCL assigning your agreements, herein, and transferring any information obtained pursuant to this Application or relating to your finance or lease contract, to any third party to which your contract may be transferred, provided that such third party agrees to hold, use and disclose such information for the same purposes as Ford Credit or FCCL; and

MARKETING & OTHER PURPOSES

(v) Ford Credit or FCCL holding, using and disclosing to Dealer and affiliated companies, such as Ford Motor Company of Canada, Limited, and such parties (including third parties acting for them or on their behalf) collecting, holding and using, your contact information and information about your finance or lease contract, in order to offer you automotive or financial services products that may be of interest to you and in order to determine satisfaction with your sales experience and/or products and services relating to your finance or lease contract or vehicle and in order to evaluate your credit, even after your finance or lease contract has terminated.

Check the box on this Application Statement if you do not want information to be used for the purpose in (v) above, or give us reasonable notice, at any time, at the toll-free telephone number, or electronically at the website, listed below.

C. ACCESS TO INFORMATION

A file of some or all personal information referred to above will be kept by the Dealer at its place of business, and by Ford Credit or FCCL or any affiliated company, as applicable, at the Ford Credit or FCCL Customer Service Centre, P.O. Box 2400, Edmonton, Alberta, T5J 5C7, and will be available to their respective employees and third parties acting for them or on their behalf who require access to the information for purposes outlined above. You have a general right to access and rectify the information contained in the file, by giving written notice to the Dealer, at its place of business, or to Ford Credit or FCCL or any affiliated company, at the address above, Attention: Privacy Office. You may also obtain access to, or challenge the accuracy of the information contained in, any credit report referred to in A. above by giving written notice to (i) Equifax, at Consumer Relations Dept., Box 190 Jean Talon Station, Montreal, Quebec, H1S 2Z2, or (ii) to TransUnion, for all provinces except Quebec, Attention: Consumer Relations Department, P.O. Box 338, LCD1, Hamilton, Ontario, L8L 7W2, or for Quebec residents, to TransUnion, Centre de relations aux consommateurs, 1 place Laval Ouest, bureau 370, Laval (Qu?bec) H7N 1A1, as applicable.

Some or all of the personal information referred to above may be processed or held in other jurisdictions, including the United States, or our oveaseas offices where we use other means to provide a comparable level of security and whose laws may permit its governmental, law enforcement or regulatory authorities or courts to have access to such personal information.

To obtain a copy of the Ford Credit or FCCL Privacy Statement, which sets out our safeguards and other privacy policies, including policies respecting service providers outside of Canada, or a current list of our affiliated companies referred to in B(v) above, please contact our Customer Service Centre at the toll-free telephone number, or electronically at the website, listed below. If you have a question or concern about the collection of personal information by Ford Credit or FCCL, or the collection, use, disclosure or storage of personal information by service providers outside of Canada, please contact our Privacy Officer by email at fcpriv@.

Ford Credit or FCCL

1-877-636-7346



I certify that the information on this Application Statement is true and correct to the best of my knowledge and belief, that I have attained the age of majority, and that I have read the terms forming part of this Application, and understand that they permit the collection, use and disclosure of my personal information for the purposes specified.

X Applicant's Signature: _______________________________________________________

Date (mm/dd/yyyy): ___________________

* a division of Canadian Road Leasing Company** ** a limited partnership between Canadian Road Management Company and Canadian Road Holdings Company

FC-27141 (04/2013) Previous editions may NOT be used.

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