Apply For Financing

Applicant Information

Contact Information

Salutation: *
Phone Number: *
First Name: * Mobile Number: *
Middle Name: Email Address: *
Last Name: *
Suffix:

Current Home Address

Address Type: *
City: *
Street Number: * Province: *
Street Name: * Postal Code: *
Street Type:
Years at Address: *
Street Direction: Months at Address: *
Unit Number:

Personal Information

Date of Birth: * Marital Status: *
SIN: Gender: *

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 Promotions 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.
*

Housing & Employment

Housing Information

Home Status: *
Additional Info.:
Monthly Housing Payment: * Market Value:
Mortgage Amount:

Current Employment Information

Employment Status: *
Address Type: *
Employment Type: *
Street Number: *
Employer: * Street Name: *
Occupation: * Street Type:
Work Contact Phone: * Street Direction:
Work Contact Ext.: Unit Number:
Years at Address: * City: *
Months at Address: * Province: *
Postal Code: *

Current Income Information

Income Amount: * Other Income Amount:
Income Frequency: *
Other Income Frequency:
Other Income Type:
Other Income Description:

Loan Asset

Financing Information

Financed Amount: Cash Down:
Term:
Monthly Payment:

Desired Purchase

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

Additional Info.

Sales Rep.:
Referral Source:
Comments & Feedback: