Please Note: Fields marked with * are required fields.

General Information:

You are:

The Applicant The Cosignor

If you checked Cosignor,
please indicate here
who you are cosigning for:

First Name *

Middle Initial(s)

Last Name *

Email Address

Date of Birth *

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 19

Social Insurance Number

Driver's License Number

Home Phone

Day Phone *
Contact will be done confidentially

Fax Number

Call before Fax?

Yes No

Personal Reference Name #1:

Personal Reference Phone #1:

Personal Reference Name #2:

Personal Reference Name #2:

Current Address:

Apt. Number

Address *

City & Province *

Postal Code *

Residing Since?

Own Rent

Monthly Payment ($)

Landlord or Mortgage Co.

Employment Information:

Occupation

Employer

Employer Contact

Business Phone

Employee Since?

Jan Feb Mar April May June July Aug Sept Oct Nov Dec 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Status

Gross Monthly Income ($)

Net Monthly Income ($)

Other Income:

Source

Amount/Month ($)

Procedure Information:

Name of Pet*

Amount of Financing Required ($)

Procedure Type

Approx. Date of Procedure

Veterinary or Clinic Name

Contact Person

Telephone

Fax

Additional Information:

If you require an immediate answer or have special instructions or information,
please indicate in the space provided here:

If you have any further information, or have any questions, please contact us at
1-888-689-9876, we would be happy to assist you.

Terms & Conditions
I/we understand that the above information (the "Collected Information") is being collected for the purpose of obtaining credit from Medicard Finance Inc. ("Medicard") and is warranted to be true and complete. I/we hereby authorize and consent to the collection of the Collected Information and to the making by Medicard, its successors and assigns of whatever credit investigations and/or employment and income confirmations Medicard or its successors and assigns may deem appropriate from time to time, and to the disclosure, sharing or exchange of the Collected Information and any report or information based thereon for these purposes with credit reporting agencies, and amongst Medicard, its successors and assigns or any company with whom I/we have or propose to have a financial relationship.

I/we accept this as written notice of Medicard, its affiliates, service providers and professional advisors (collectively Medicard) receiving, disclosing, exchanging and using any Collected Information and any other personal information (collectively the "Personal Information") about me/us for the purposes set out below

MEDICARD, its affiliates and service providers may use any Information relating to me/us:
a) to establish, maintain and administer my/our Financing;
b) to determine my/our eligibility for products, goods and services offered by MEDICARD including monitoring my/our purchase history as well as evaluating my/our credit standing;
c) to determine the suitability of benefits, services or enhancements, and/or which other product or service offers may be of interest to me/us;
d) to promote and market additional products, goods and services offered by MEDICARD including by means of direct marketing, &
e) to comply with legal and regulatory requirements

I/we hereby also authorize any person who is contacted in this regard to provide such information.
I /we acknowledge that my/our consent to "Use of Personal Information" includes:
a) MEDICARD providing the service provider who accepts the financing for which I/we am applying (the "Retailer") with MEDICARD's decision with respect to this application and if my/our Card application is accepted, my/our Account number and any other information which the Retailer may reasonably require;
b) The Retailer providing MEDICARD with information related to any loyalty or reward program offered by that retailer where such loyalty or reward programs is administered by MEDICARD and MEDICARD's receipt, exchange and use of such information.

Credit will be extended by MEDICARD upon approval of this application and I/we request an account card be issued to me/us and any renewal or replacements thereof. All information provided by me/us in connection with this application is true, accurate and complete in all respects.

I/we consent to the creation of a Personal Information file containing credit and other personal information. Only those employees of MEDICARD whose job functions involve assessment of creditworthiness, credit applications, monitoring, processing of payments and matters relating to the purpose of the file, will have access to my/our file.
I/we understand I/we can tell you to stop using Personal Information about me/us in order to promote and market additional products, goods and services offered by MEDICARD. I agree that my/our Social Insurance Number may be used as an aid to identify me/us with credit bureaus and others for credit history file matching and other administrative purposes.

I/we also consent to the retention of Personal Information about me/us for as long as is needed for the purposes described above, even after I/we cease to be a customer. In order to ensure the accuracy, completeness and integrity of the credit reporting system, I/we specifically consent to the continued disclosure of my/our Personal Information to credit bureaus even after the loan or credit facility has been retired.

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