Sales Rep:

Date: 05/24/2025

Marketing Source:

EVENT REGISTRATION SURVEY

CUSTOMER INFORMATION

First Name:

Last Name:

Address:

City:

State:

Zip:

Cell:

Work:

Home:

Email:

Time at Residence:

Rent Own

Amount:

Date of Birth:

SSN:

Employer:

Position:

Time at Job:

Hourly:

Hours per Week:

Previous Employer:

Position:

Time at Job:

Hourly:

Hours per Week:

Previous Residence:

City:

State:

Zip:

CO-BUYER INFORMATION

Co First Name:

Co Last Name:

Address:

City:

State:

Zip:

Cell:

Work:

Home:

Email:

Time at Residence:

Rent Own

Amount:

Date of Birth:

SSN:

Employer:

Position:

Time at Job:

Hourly:

Hours per Week:

Previous Employer:

Position:

Time at Job:

Hourly:

Hours per Week:

Previous Residence:

City:

State:

Zip:

CURRENT VEHICLE INFORMATION

Make:

Model:

Year:

VIN:

Current Mileage:

Trade-In Value:

Payoff:

Where Financed:

Monthly Payment:

DESIRED VEHICLE

Car:

Van:

Truck:

SUV:

Cash Down/Customer Investment:

Desired Payment:

CUSTOMER ACKNOWLEDGEMENT

I hereby state that I authorize dealer to obtain information as may be necessary to expedite my purchase of a vehicle and see if I qualify for any special program. I further attest that I am at least 18 years old.

Applicant Signature

Co-Applicant Signature

Date

Next Registration