Applicant Information

Contact Information

Salutation: * Dr. Mr. Ms. Miss Mrs. Phone Number: * First Name: * Mobile Number: * Middle Name: Email Address: * Last Name: * Suffix: I II III IV JR SR

Current Home Address

Address Type: * Street Rural Route Postal Box City: * Street Number: * Province: * Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Street Name: * Postal Code: * Street Type: ABBEY ACRES ALLEE ALLEY AUTOROUTE AVENUE BAY BEACH BEND BLVD BOUL BYPASS CAMPUS CAPE CARRE CENTRE CERCLE CHASE CHEMIN CIRCLE CIRCUIT CLOSE COMMON CONCESSION CORNERS COTE COUR COURS COURT COVE CRESCENT CROISSANT CROSSING CUL-DE-SAC DALE DELL DIVERSION DOWNS DRIVE END ESPLANADE ESTATES EXPRESSWAY EXTENSION FIELD FREEWAY FRONT GARDENS GATE GLADE GLEN GREEN GROUNDS GROVE HARBOUR HEATH HEIGHTS HIGHLANDS HIGHWAY HILL HOLLOW ILE IMPASSE INLET ISLAND KEY KNOLL LANDNG LANE LIMITS LINE LINK LOOKOUT LOOP MALL MANOR MAZE MEADOW MEWS MONTEE MOUNT MOUNTAIN PARADE PARC PARK PARKWAY PASSAGE PATH PATHWAY PLACE PLATEAU PLAZA POINT POINTE PRIVATE PROMENADE QUAI QUAY RAMP RANG RANGE RIDGE RISE ROAD ROUTE ROW RUE RUELLE RUN SENTIER SQUARE STREET SUBDIVISION TERRACE TERRASSE TOWNLINE TRAIL TURNABOUT VALE VIEW VILLAGE VILLAS VISTA VOIE WALK WAY WHARF WOOD WYND Years at Address: * Street Direction: East North North East North West South South East South West West Months at Address: * Unit Number:

Previous Home Address

Address Type: * Street Rural Route Postal Box City: * Street Number: * Province: * Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Street Name: * Postal Code: * Street Type: ABBEY ACRES ALLEE ALLEY AUTOROUTE AVENUE BAY BEACH BEND BLVD BOUL BYPASS CAMPUS CAPE CARRE CENTRE CERCLE CHASE CHEMIN CIRCLE CIRCUIT CLOSE COMMON CONCESSION CORNERS COTE COUR COURS COURT COVE CRESCENT CROISSANT CROSSING CUL-DE-SAC DALE DELL DIVERSION DOWNS DRIVE END ESPLANADE ESTATES EXPRESSWAY EXTENSION FIELD FREEWAY FRONT GARDENS GATE GLADE GLEN GREEN GROUNDS GROVE HARBOUR HEATH HEIGHTS HIGHLANDS HIGHWAY HILL HOLLOW ILE IMPASSE INLET ISLAND KEY KNOLL LANDNG LANE LIMITS LINE LINK LOOKOUT LOOP MALL MANOR MAZE MEADOW MEWS MONTEE MOUNT MOUNTAIN PARADE PARC PARK PARKWAY PASSAGE PATH PATHWAY PLACE PLATEAU PLAZA POINT POINTE PRIVATE PROMENADE QUAI QUAY RAMP RANG RANGE RIDGE RISE ROAD ROUTE ROW RUE RUELLE RUN SENTIER SQUARE STREET SUBDIVISION TERRACE TERRASSE TOWNLINE TRAIL TURNABOUT VALE VIEW VILLAGE VILLAS VISTA VOIE WALK WAY WHARF WOOD WYND Years at Address: * Street Direction: East North North East North West South South East South West West Months at Address: * Unit Number:

Personal Information

Date of Birth: * Marital Status: * Divorced Married Common Law Widow/Widower Separated Single SIN: Gender: * Male Female

Disclosure & Privacy Notice

By checking this box, I consent to the collection, use and disclosure of my personal information as described in this paragraph. I agree that the personal information provided above may be used and disclosed by segway demo5 and/or its agents or service providers (collectively, the "Dealer") as necessary to obtain credit, financial and related personal information (including a credit or consumer information report) about me from any credit bureau or credit reporting agency, and to advise me on credit availability in connection with product and/or service purchase financing. I further agree that the personal information provided above may be disclosed to the provider of Dealer’s website hosting or related services for the purpose of enabling Dealer to access my personal information for marketing purposes. Personal information I provide and credit information obtained may also be retained by Dealer and used to facilitate the application process should I subsequently choose to apply for credit through Dealer. I have read and agree to the Terms & Conditions above.*

Housing & Employment

Housing Information

Home Status: * Own with Mortgage Own Free & Clear Own Mobile Home Rent With Parents Reserve Housing Other Additional Info.: Monthly Housing Payment: * Market Value: Mortgage Amount:

Current Employment Information

Employment Status: * Full time Full Time (Probation) Part Time (Casual) Part Time (Regular) Retired Seasonal Summer Seasonal Winter Self Employed Address Type: * Street Rural Route Postal Box Employment Type: * At home Executive Labourer Management Office Staff Other Production Professional Retired Sales Self-Employed Service Student Trades Unemployed Street Number: * Employer: * Street Name: * Occupation: * Street Type: ABBEY ACRES ALLEE ALLEY AUTOROUTE AVENUE BAY BEACH BEND BLVD BOUL BYPASS CAMPUS CAPE CARRE CENTRE CERCLE CHASE CHEMIN CIRCLE CIRCUIT CLOSE COMMON CONCESSION CORNERS COTE COUR COURS COURT COVE CRESCENT CROISSANT CROSSING CUL-DE-SAC DALE DELL DIVERSION DOWNS DRIVE END ESPLANADE ESTATES EXPRESSWAY EXTENSION FIELD FREEWAY FRONT GARDENS GATE GLADE GLEN GREEN GROUNDS GROVE HARBOUR HEATH HEIGHTS HIGHLANDS HIGHWAY HILL HOLLOW ILE IMPASSE INLET ISLAND KEY KNOLL LANDNG LANE LIMITS LINE LINK LOOKOUT LOOP MALL MANOR MAZE MEADOW MEWS MONTEE MOUNT MOUNTAIN PARADE PARC PARK PARKWAY PASSAGE PATH PATHWAY PLACE PLATEAU PLAZA POINT POINTE PRIVATE PROMENADE QUAI QUAY RAMP RANG RANGE RIDGE RISE ROAD ROUTE ROW RUE RUELLE RUN SENTIER SQUARE STREET SUBDIVISION TERRACE TERRASSE TOWNLINE TRAIL TURNABOUT VALE VIEW VILLAGE VILLAS VISTA VOIE WALK WAY WHARF WOOD WYND Work Contact Phone: * Street Direction: East North North East North West South South East South West West Work Contact Ext.: Unit Number: Years at Address: * City: * Months at Address: * Province: * Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Postal Code: *

Current Income Information

Income Amount: * Other Income Amount: Income Frequency: * Year Month Week Other Income Frequency: Year Month Week Other Income Type: Car Allowance Child Support/Alimony Disability Payments Investment Income Other Pensions Rental Income Workers Compensation Other Income Description:

Loan Asset

Financing Information

Financed Amount: Cash Down: Term: 12 24 36 48 60 72 84 Monthly Payment: I have a Trade-in.

Trade-in Information

Year: 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 Make: Model: Odometer (kms):

Desired Purchase

If the vehicle you are looking for is not listed above, please enter it manually in the Comments section. Asset Type: Leisure VIN / HIN / Serial No: Stock Number:

Additional Info.

Sales Rep.: Referral Source: AutoHound AutoTrader Family/Friend Internet Newspaper/Flyer Other (please specify with a comment) Radio Television Comments & Feedback: