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Contact Information

First Name: *

Last Name: *

Phone: *

Email: *

Marital Status:

Date of Birth:

Social Insurance Number:

Desired Vehicle

Make:

Model:

Year:

Vehicle Stock Number (if applicable):

Home

Address: *

City: *

Province: *

Postal Code: *

Are you:

At this address since:

Previous Address (if you've been living at your current address for less than 2 years)

Previous Address:

Previous City:

Previous Province:

Previous Postal Code:

How long did you live here?

Years

Months

Work

Employer's Name:

Occupation:

Address:

City:

Province:

Postal Code:

Phone:

Since:

Status:

Annual Gross Salary:

Previous Work

If you've been working at your current job for less than 2 years:

Previous Employer's Name:

Previous Occupation:

Previous Address:

Previous City:

Previous Province:

Previous Postal Code:

Previous Phone:

Years Worked Previously:

Disclosure & Privacy Notice

By checking this box, I consent to the collection, use, and disclosure of my personal information as described in this paragraph. I agree that the personal information provided above may be used and disclosed by 6778160 Canada Inc. and/or its agents or service providers (collectively, the "Dealer") as necessary to obtain credit, financial, and related personal information (including a credit or consumer information report) about me from any credit bureau or credit reporting agency, and to advise me on credit availability in connection with product and/or service purchase financing. I further agree that the personal information provided above may be disclosed to the provider of the Dealer’s website hosting or related services for the purpose of enabling the Dealer to access my personal information for marketing purposes. Personal information I provide and credit information obtained may also be retained by the Dealer and used to facilitate the application process should I subsequently choose to apply for credit through the Dealer.

I have read and agree to the Terms & Conditions above.