Date MM slash DD slash YYYY Client Name First Last OccupationPlace of WorkIndustrySocial Insurance NumberCanadian Citizen Yes No Other Date of Birth MM slash DD slash YYYY Place of BirthMailing Address Is your physical address different from your mailing address?*(required) Yes No Physical AddressHome Phone NumberCell Phone NumberBusiness Phone NumberHome Email Office Email Alternate Contact PersonAlternate Contact Phone NumberSource of referral / How did you hear about us?CONFIRMATION THAT THIS TRANSACTION IS FOR THE BENEFIT OF YOURSELF AND NOT A THIRD PARTYSelect the option that corresponds with your circumstance. This transaction is for my own purpose/own use (your purchasing or selling your own home/your mortgage proceeds for you own use/sale proceeds for your own use). This transaction is for the benefit of a 3rd party (ie Funds from mortgage to give to another person or acting by Power of Attorney for another person. PLEASE READ THE FOLLOWING LIST OF POSITIONS AND SELECT THE APPLICABLE OPTION BELOW Governor General, lieutenant governor or head of government; Member of the Senate of House of Commons or member of a legislature Deputy minister or equivalent rank Ambassador, or attache or counsellor of an ambassador Military office with a rank of general or above President of a corporation that is wholly owned directly by Her Majesty if Right of Canada or a province Head of a government agency Judge of an appellate court in a province, the Federal Court of Appeal or the Supreme Court of Canada Leader or president of a political party represented in a legislature or Mayor Confirmation I confirm that neither myself, nor any of my family members or close acquaintances have held any of the above positions I confirm that either myself, or a family member, or close acquaintances have held one of the above positions Please provide details of the individual that held the position, including relationship to yourself:
