VIP Name:
Address:
City:
State:
Zip:
Home Phone:
Work Phone:
Email:
Current Customer
Previous Customer
New Customer
VEHICLE PREFERENCE
New
Pre-Owned
Car
Truck
Minivan
SUV
Desired vehicle features:
What new features are you most interested
in compared to your current vehicle?
Why are these features important?
CURRENT VEHICLE
Year:
Make:
Model:
Name on Registration:
Title:
Amount Still Owed:
Months of Payments Left:
Bank / Financing Co.:
Selling
Keeping
VIP
Monthly Payment Goal: $
Can you drive home a vehicle once payment goal is met?
Yes
No
If you can’t purchase today, why?
Credit Report Authorization:
(please type the word "yes")
Thank you for taking the time to complete this survey!