EmailMe Form - Financing Application

Model of Daymak Ebike *

Sales Representative

Salutation *

Name *

First Last

Email *

Phone *

### - ### - ####

Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Do you RENT or OWN *

Rent

Own

How long have you been living at this address? *

Date of Birth *

MM / DD / YYYY

What is your Social Insurance Number? *

Marital Status

Married

Single

Employment Information

Where do you work? (Company Name) *

Job Title *

What is your monthly income before taxes? *

Work Phone Number *

### - ### - ####

How long have you been with your current employer? *

Co Applicant Information

Will you be adding a Co-Applicant? *

No

Yes

Co-Applicant Salutation *

Co-Applicant Name *

First Last

Co-Applicant Email *

Co-Applicant Phone *

### - ### - ####

Co-Applicant Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Does Co-Applicant RENT or OWN *

Rent

Own

How long has Co-Applicant been living at this address? *

What is Co-Applicant's Social Insurance Number? *

Co-Applicant Marital Status *

Married

Single

Where does co-applicant work? (Company Name) *

Co-Applicant Job Title *

What is Co-Applicant's monthly income before taxes? *

Co-Applicant Work Phone *

### - ### - ####

How long has Co-Applicant been with your current employer? *

Co Applicant Date of Birth *

MM / DD / YYYY