Application Form - HearCanada

Personal informations

First name *

Last name *

Gender

Email address *

Birth date *

Phone number *

Clinic

Clinic *

Patient Number *

Loan informations

Term length *

Debit day

Invoice amount *

Bank

Other Banks

Transit number

Account number

I confirm that the information provided is current and accurate and that I understand and accept the terms and conditions.
I agree that HearCanada may contact me by email using the contact information submitted in this form for loan related purposes.
I confirm that I have read the Fin Expert inc. consent form, accept the terms and understand the information relating to the collection, use and retention of my personal information by Fin Expert inc. *