Priority Capital Inc.

Tel:

416-880-1397

Fax:

416-880-1397

Email:

Web:

Address:

505 Consumers Road Suite 707 Toronto, Ontario M2J 4V8

PERSONAL FACILITY APPLICATION

Your Status *

Note: You may be asked for a copy of licence and photo.

Your Home *
If owned, is your Home a
Owned by:
Marital status *
Spouse Status *
Are you now or have you been involved in any litigation? *
Have you ever been bankrupt? *
Have you ever had a bond application declined? *
Have you ever compromised with creditors? *

ASSETS

LIABILITIES

CERTIFICATION

I hereby certify that the information provided in this personal statement is true, accurate and complete. Permission is hereby granted for a confidential credit investigation. A copy of this form shall be good and sufficient authority for anyone having confidential or other information about the financial position of the APPLICANT herein to disclose such information to PRIORITY CAPITAL INC. ("PCI") upon request.

If representations are subsequently found to be incorrect or incomplete, PCI reserve the right to reject this application and cancel any contract that may be negotiable and shall not be obliged to fulfil any agreement with the APPLICANT, verbal or written. APPLICANT agrees that any expenses incurred by PCI , because of reliance by it upon incomplete or incorrect  statements made by the APPLICANT herein are chargeable to the APPLICANT.