Canada Custom Autoworks Repair Application

All fields with an asterisk * are mandatory

Full Name *

First

Last

Date of Birth: *

Driver's license number:

Email *

Phone *

Home Address: (As per drivers licence.) *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Time at current address: *

Is the vehicle jointly owned? *

Yes
No

VEHICLE INFORMATION

Year: *

Make: *

Model: *

Trim:

Vin # *

KMS: *

Is there an existing loan on your vehicle? *

Yes
No

If "Yes" Amount Owed and Institution.

e.g.$1000.00 - Bank of Canada

Vehicle Registration Status: *

Active
Rebuilt

Name of Canada Custom Autoworks Representative (if applicable)

Repair / Service Order # *

Cost of repair / loan amount to borrow? *

CREDIT CHECK OPTIONS: *

NO CREDIT CHECK - The application information I am providing will not be used to asses my credit worthiness. I understand this does not make me eligible for a reduced interest rate and the rate will be 24.99% - 29.99%.
CREDIT CHECK - I understand the credit information I am providing will be used to asses my credit worthiness for this loan. I also understand I am applying for the lower interest rate program which, upon review of my credit, I may or may not qualify for. Subject to the amount borrowed and my credit score I understand rates vary between 14.99% - 29.99%.

Disclosure Statement: *

I/We certify all the information in this application is true and complete. I/We acknowledge the personal information gathered may be used by Rossi Financial Inc. to assess the eligibility of my vehicle for the program. If the Credit Check option is selected the information will be used to assess my credit worthiness, administer the contract and perform services as requested by me. Rossi Financial may disclose this information to third parties such as but not limited to credit reporting agencies, financial institutions, finance companies, and my insurance agent or company. Rossi Financial may also disclose this information where required bylaw. By signing below, I/We consent to these uses and disclosures and my submission is an acceptance to authorize the obtaining and release of information as it pertains to processing the application.

You certify you have requested all correspondence and Loan documentation in English.

Signature *

Clear Signature

Pictures required: Drivers licence, Registration, 4x Exterior (front, rear, left, right), VIN number, Odometer, Interior (front, rear, hatch, box etc.)

Drag & Drop Files, Choose Files to Upload You can upload up to 15 files.

NOTE: If you need to send pictures seperatly send to repair @ rossifinancial.ca

Today's Date: *