Customer Name:*
Date of birth:*
Social Insurance Number:*
Cell Phone:*
✓ Valid
Street Address:*
City:*
Postal Code:
How long have you lived at this address (Years)? (If less than 1 year, put 1)*
Do you rent or own your home?*
Select One
Rent
Own
Monthly rental / mortgage payment:*
Previous address if current location is less than two years.
How long did you live there (Years)? (If less than 1 year, put 1)
Marital Status:*
Current Bank / Accounts Held:*
How many years have you banked there?*
Your Email Address:*
Employer Name:*
Occupation:*
Years employed (if less than 1, put 1)*
Employer Phone:*
Employer Address:
City:*
Postal Code2:*
Province:*
Select One
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Gross Monthly Income:*
Please do not fill out "Other Income" and "Previous Employment" fields if they do not apply.
Other Income:
Source of Other Income:
Previous Occupation, if current employment less than 2 years..
Years Employed There: (If less than 1, put 1)
Name:
Phone:
Address:
city:
Postal Code3:
Province:
Select One
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Preferred Payment (?):*
I certify that all of the statements in this application are true and complete and are made for the purpose of obtaining credit. I agree to provide and/or authorize West Country Motors' affiliate automobile dealers or lending partners to obtain such additional information as may be required, including credit reports, in order to complete the processing of my application.
Date:*