Name

Email Address

I am over 18 years of age I am over 18 years of age yes no

I am in full time employment I am in full time employment yes no

The car I am buying is over €5,000 The car I am buying is over €5,000 yes no

Date of birth --/--/----

Place of birth

Marital Status

Phone number

Address

Time at address

Previous address -if less than 3 years at current address

Employment Type Employment Type Permanent Temporary Contract

Occupation

Employer name

Employer address

Time with Employer (Years/months)

No of dependant children

Net salary (per month)

Other income (per month)

Past employment (if less than 3 years in current position)

Past employer's name

Past employer's address

Past employment duration

Bank

Branch

Time with branch

Car Details

Trade In ( Deposit + Trade in Value must be minimum 10% car value) Trade In ( Deposit + Trade in Value must be minimum 10% car value)YesNo

Deposit amount

Trade in value

Finance Term Finance Term36 months48 months60 months

Finance amount

Data Protection and Consents Data Protection and Consents I AGREE TO THE FOLLOWING :Data Protection and Consents The information that you provide on this proposal form will be forwarded to one or more financial institutions, being members of the Irish Finance Houses Association, and will be used by them for the purposes of assessing the suitability for you of their finance products, potentially offering you a product or a quote. As part of this process, credit searches will be made with one or more credit reference agencies, including the Irish Credit Bureau (ICB), which will make a record of the search. Details of any agreement you enter into, and your conduct of that agreement, may be shared with the credit reference agencies, ICB and their members. Searches may also be carried out to verify your identity, and you may be contacted directly (including by telephone) for the purposes of verifying the information on this form. Credit scoring and other automated decision-making process may be used. By ticking I certify that I consent to the use and disclosure of this information for the purposes set out here. I acknowledge that the recipients of this information are authorised to contact me and to disclose any material misstatements of fact on this proposal to their members and other relevant bodies.