CUSTOMER REQUIREMENT INFORMATION

Personal Details

Forenames                   

Surname                          

Date of Birth                

House Name/No.          

Street                           

Town/City                    

Postcode                      

Time at Address           years    months

Home Tel. No.              

Mobile No.                    

Email Address              

Residential Status        Owner Tenant Living with Parents

Marital Status               Single Married Divorced Separated

Previous Address Details (if less than 3 years)

House Name/No.          

Street                           

Town/City                    

Postcode                      

Time at Address           years    months

Vehicle Requirement

Make & Model              

New or Used?                New Used

Fuel Type?                    Petrol Diesel LPG Dual Fuel

Must Have Features (Air con etc.)

Economic Insurance?    Yes No

Require finance?           Yes No

Monthly Budget?       £ 

Colour Preference     1     2    3  

Employment Details (for the last 3 years)

Employer                      

Employer Address        

Town/City                    

Postcode                      

Time with Employer      years    months

Previous Employer (1) 

Postcode                      

Time with Employer      years    months

Previous Employer (2) 

Postcode                      

Time with Employer      years    months