Speed up your purchase or your lease
by making an online credit check!

This is not an official document.
We will contact you soon to complete the process.
Personal information
*Fields marked with an asterisk are mandatory
First name: *
Last name: *
Birth date:
(YYYY/MM/DD)		 / /
Social insurance number:
Driver's license number: *
E-mail: *
Telephone:    - ext.:
Fax:    -
Address:
City:
Province:
Postal code: (format : A9A 9A9)
At this address since:
(years or months)
Situation
Owner Tenant Other
Owner
Mortgage institution:   
Telephone:       -
Account number:   
Current employer
Company or owner:   
Since:
(years or months)		   
Position:   
Telephone:       - ext:
Income:   
Previous employer
Company or owner:   
Employment duration:
(years or months)		   
Position:   
Telephone:       - ext:
Second previous employer
Company or owner:   
Employment duration:
(années ou mois)		   
Position:   
Telephone:       - ext:
Other source of income
Specify:   
Amount:    $
Other assets (ex: RRSPs, investments, etc.)
Specify:   
Nature:   
Value:    $
Financed vehicle information
*Fields marked with an asterisk are mandatory
Desired vehicle
Make: *
Model: *
Year: *
I plan on getting this car in: *
Cash down payment: * $
Monthly budget: * $ /month
Trade-in
Make:
Model:
Year:
Kilometers: km
Value: $
Balance: $
Bank account information
*All fields are mandatory
Financial institution name: *
Address: *
Telephone: *    -
Have you ever been bankrupt?: *
Yes No
Do you have a credit card?: *
Yes No
Visa
Mastercard
Amex
Other
Number :
Other bank account (if applicable)
Financial institution name:   
Address:   
Telephone:       -
This hereby authorizes Lallo Mazda and affiliate companies to obtain a credit report on all the information provided above.

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