Secure Online Personal Credit Application
Personal Information
Red Labels Indicate Required Information!
Applicants Name:
Date of Birth:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
Social Insurance Number:
Drivers Licence Number:
Address:
City:
Province:
Postal Code:
How Long at Current Address:
Months
0
3
6
9
Years
1
2
3
4
5 or more
E-Mail Address:
Daytime Phone Number:
Evening Phone Number:
Pager/Cell Number:
Fax Number:
Preferred Method of Contact:
Pick One
E-mail
Day Phone
Evening Phone
Pager/Cell
Fax
Spouse/CoApplicant Name:
Date of Birth:
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
Social Insurance Number:
Drivers Licence Number:
Address:
City:
Province:
Postal Code:
How Long at Current Address:
Months
0
3
6
9
Years
1
2
3
4
5 or more
E-Mail Address
Daytime Phone Number:
Evening Phone Number:
Pager/Cell Number:
Fax Number:
Preferred Method of Contact:
Pick One
E-mail
Day Phone
Evening Phone
Pager/Cell
Fax
Current Residence:
Pick One
Rent
Own
Room and Board
Rent/Mortgage Amount:
If you have been in your current residence less than two and one half years you must complete the following:
Previous Address:
City:
Province:
Postal Code:
How Long at Previous Address:
Months
0
3
6
9
Years
1
2
3
4
5 or more
Employment Information
Current Employer:
Employer Address:
Employer Telephone Number:
How Long:
Months
Less Than 6
6
9
Years
1
2
3
4
5 or more
Occupation:
Gross Income:
Former Employer Address:
How Long:
Months
Less Than 6
6
9
Years
1
2
3
4
5 or more
CoApplicant Employer:
Employer Address:
Employer Telephone Number:
How Long:
Months
Less Than 6
6
9
Years
1
2
3
4
5 or more
Occupation:
Gross Income:
Other Income Source:
Bank Account Information
Financial Institution Name:
Branch and Address:
Account Number:
Type of Account:
Financial Institution Name:
Branch and Address:
Account Number:
Type of Account:
Credit References
Asset Credit Description:
Value:
Creditor Name and Address:
Balance Owing:
Monthly Payment:
Asset Credit Description:
Value:
Creditor Name and Address:
Balance Owing:
Monthly Payment:
Asset Credit Description:
Value:
Creditor Name and Address:
Balance Owing:
Monthly Payment:
Asset Credit Description:
Value:
Creditor Name and Address:
Balance Owing:
Monthly Payment:
Asset Credit Description:
Value:
Creditor Name and Address:
Balance Owing:
Monthly Payment:
Personal References
Name and Address:
Relationship:
How Long:
Telephone:
Name and Address:
Relationship:
How Long:
Telephone:
Name and Address:
Relationship:
How Long:
Telephone:
A consumer / personal report containing credit, medical or personal information will be referred to in connection with this application and upon clicking the 'Submit Request' button the applicant herby consents to the preparation of such a report, and the consumer further consents to Comox Valley Dodge Chrysler Jeep obtaining credit, medical or personal information reports representing the applicant from consumer reporting agencies.
The applicant hereby consents and acknowledges Comox Valley Dodge Chrysler Jeep and/or its successors or assigns shall have the right to disclose any information contained in a consumer/personal report on the applicant to other credit grantors or consumer reporting agencies in its own discretion or upon referral of the applicant.