*Fields marked with an asterisk are mandatory
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I plan to buy
(or lease) a vehicle in: |
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PERSONAL INFORMATION
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| *Name: |
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| Date of birth (year/month/day): |
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| Social Insurance Number: |
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| *Driver's licence number: |
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| *E-mail: |
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| Phone (with area code): |
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| Fax (with area code): |
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| Address: |
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| City: |
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| Province: |
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| Postal Code: |
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| At this address since: |
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OWNER (if applicable)
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| Mortgage Institution: |
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| Phone (with area code): |
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| Account number: |
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TENANT (if applicable)
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| Name of landlord: |
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| Phone (with area code): |
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| Monthly Rent $: |
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OTHER (if applicable)
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| Specify: |
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| Balance $: |
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| House Value $: |
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PRESENT EMPLOYER
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| Company or Owner: |
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| How long (years, months): |
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| Position: |
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| Phone at work: |
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| Income $: |
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PREVIOUS EMPLOYER
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| Company or Owner: |
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| How long (years,months): |
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| Position: |
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| Phone at work: |
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2ND PREVIOUS EMPLOYER
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| Company or Owner: |
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| How long (years,months): |
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| Position: |
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| Phone at work: |
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OTHER SOURCE OF INCOME
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| Specify: |
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| Amount $: |
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ASSETS, OTHER THAN ABOVE (EX: RRSPs, INVESTMENTS, ETC.)
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| Specify: |
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| Nature: |
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| Value $: |
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INFORMATION ON THE CAR TO BE FINANCED
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Desired vehicle: |
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Trade-in vehicle: |
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Cash down payment: |
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| Monthly budget: |
/month |
BANK ACCOUNT INFORMATION
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| Bank Name: |
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| Address: |
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| Phone (with area code): |
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| Have you ever been bankrupt? |
No Yes |
| Do you have a credit card? |
No Yes |
| If yes, specify the type: |
Visa Mastercard Amex Other |
| If yes, specify the number: |
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OTHER BANK ACCOUNT INFORMATION
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| Bank Name: |
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| Address: |
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| Phone (with area code): |
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This hereby authorizes Desjardins Ste-Adèle Marine and affiliate companies to obtain a credit report on all the information provided above.
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YES! I want to receive information on future contests, surveys, special promotions and new content from "Desjardins Ste-Adèle Marine".
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