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First Name *

Last Name *

Telephone Number *

Email Address *

What is your combined household income? *

How much have you saved as a downpayment? *

Total debts (credit cards, loans, lines of credit) *

Have you ever filed for bankruptcy? *

If yes, who filed?

Have you been discharged from bankruptcy?

If Yes when was the bankruptcy discharged?

Have you ever had a consumer proposal?

If Yes, when?

Where in or around Ottawa would you like to buy? *

How did you hear about our program? *