Name *

First Name

Last Name

Phone *

(###)

###

####

Purpose Of Finace *

New vehicle purchase

Pre-owned vehicle purchase

Balloon re-finance

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date Of Birth *

MM

DD

YYYY

When Date Did You Pass Out? *

MM

DD

YYYY

Checkbox *

Customer Declaration Statement – KPM Automotive Ltd is a licensed credit broker and not a lender from whom written details are available on request. credit application made to KPM Automotive is subject to possible assessment by a credit provider using a process known as credit scoring, this includes searching the files of credit reference agencies. Searches made are recorded by the agencies concerned. Any details or supporting information made available by you in support of your application to KPM may be passed on to a credit provider without further recourse to you. Ultimately, if a facility is granted, details of it and its conduct may be passed to credit reference agencies, which many in turn make the details available to other subscribers for credit assessment and fraud prevention purposes. If the credit application is made in the name of a partnership or company, the foregoing includes where relevant, the partners of such partnership or the directors of such company. Furthermore, I/we hereby declare that the above proposal details are true and correct in every details. Please tick the box to confirm I have read and understood this statement and confirm that I accept the contents of it.

I have read and understood the contents above