Dealership Name
PurchaserCo-PurchaserCo-Signer

Does the purchaser have a Co-Signer available if needed?
YesNoMaybe

Legal Name: (First, Middle, Last) ---Mr.Mrs.Miss.
First Name

Last Name

Email

Marital Status
---SingleMarriedCommon-LawSeparatedDivorcedWidowed

Phone Number:
Address:
City:
Province:
Postal Code:

How Long:
Years:

Months:

Do you:
RentOwnReserveOther

Monthly Amount

Home Value

Mortgage Balance

Mortgage Holder:

Birth Date (mm/dd/yy)

S.I.N #

Indian Status Card

Bankruptcy:
YesNo

If you declared bankruptcy, in what year

Repossession:
YesNo

If yes, in what year & lender

Employer:

Position/Occupation:

Employer Address:

Office Phone Number:

How Long:
Years:

Months:

Full-time:
YesNo

Wage:

Wage Paid:
HrMonthlyYearly

Hours per Week:

Previous Employer (if less than 2yr at present):

Previous Employer Phone Number

How Long:
Years:

Months:

Full-time:
YesNo

Wage:

Wage Paid:
HrMonthlyYearly

Hours per Week:

Other income: Child support, alimony, pension/disability, workers comp, car allowance, home biz,
rental income, etc. Description & Amount

Other Income Amount

Purchase:

Purchase Make:

Purchase Model:

Mileage:
km

Purchase VIN:

Price:
plus tax

Trade-In:

Purchase Make:

Purchase Model:

Mileage:
km

Trade-In Value:

Trade Lien Amount:

Trade Lien Holder:

Down Payment:

Desired Payment Amount

Payment Type
Bi-WeeklyMonthly