SECTION 1

Full Name:

Address:

Are you over 19?

Is the vehicle free and clear of all financial obligations?

No:why?

Are you the sole owner of the vehicle?

No:name of other?

How much cash do you require? in $

How long do you require the loan for?

SECTION 2

Insurance Registration No:

Plate:

VIN:

Make:

Model:

Body Style:

Year:

Color:

Odometer:

Transmission:

Any damage in excess of $2,000.00, or has a rebuilt Engine?

Yes:what?

Is there collision insurance coverage on the vehicle?

How much is the collision deductible? (in $)

Insurance Expiry Date:

SECTION 3

Driver's License Number:

BC / AB:

Expiry Date:

Date of Birth:

SIN:

Eye Color:

Home Phone:

Email:

Hair Color:

Cell:

Work Phone:

Height:

Employer:

Martial Status:

Weight:

Job Title:

Address:

Spouse/Partner's Name:

Address if different from yours:

Phone:

SECTION 4

Relatives Information:

Name:

Phone:

Name:

Phone:

Friends Information:

Name:

Phone:

Name:

Phone:

Preferred Monthly Payment Method