Vehicle Shopping Client Intake Form

Vehicle Shopping Client Intake Form

Please fill out your personal details, vehicle preferences, financial information, and other preferences to help us assist you better.
The Auto Broker

Do You LOVE getting a new car but HATE working with the dealerships? Let me handle the dealer for you.
Client Information
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Vehicle Preferences
Vehicle Option 1 - Year
Vehicle Option 1 - Make
Vehicle Option 1 - Model
Vehicle Option 1 - Trim
Vehicle Option 2 - Year
Vehicle Option 2 - Make
Vehicle Option 2 - Model
Vehicle Option 3 - Year
Vehicle Option 2 - Trim
Vehicle Option 3 - Model
Vehicle Option 3 - Make
Vehicle Option 3 - Trim
Vehicle Option 4 - Year
Vehicle Option 4 - Make
Vehicle Option 4 - Model
Vehicle Option 4 - Trim
Is the customer willing to take a vehicle with very low mileage for a slight discount?

YesNo
Preferred Colors
Lease Mileage Per Year
Financial Information
Current Monthly Payment
Down Payment Amount
Desired Monthly Payment
Do you have a trade-in vehicle?

YesNo
Year
Make
Model
VIN
Current Mileage
Existing Damage
Payoff Amount (if any)
If you have a trade-in vehicle, please kindly take clear photos of all four sides of the vehicle, the VIN number, the VIN sticker, and the odometer, and email them to Grant.Leszczynski@gmail.com. Please be sure to include your full name in the subject line.
Please upload photos showing all four sides of the vehicle, the odometer, and the VIN sticker.
Photos of the vehicle

Please upload photos of all four sides of the vehicle, the odometer, and the VIN sticker.
Cancelof
Document Uploads
Upload a picture of your driver's license

Cancelof
Upload your current insurance

Cancelof
Upload your current vehicle registration

Cancelof
Transaction Type
for this purchase
Select Transaction Type*

PurchaseLeaseCash
Are you interested in GAP coverage?

YesNo
Warranties & Protections
Would you like an extended warranty?

YesNo
Are you interested in paint protection?

YesNo
Would you like tire protection?

YesNo
Credit Range
Estimated Credit Range
Timing
What is your desired timeline for acquiring your vehicle?
Trade Ownership Status

Lease Turn InOwned
Amount Owed if Owned
Lienholder Name
Account Number
Number of Payments Remaining
A non-refundable retainer fee of $149.99 is required to initiate all vehicle searches. Once a vehicle has been located and is leased or purchased, additional fees will apply. We kindly accept electronic payments via Venmo, PayPal, and Zelle only.
Special Notes
Anything else you would like Grant to know?
PERSONAL & FINANCIAL INFORMATION DISCLOSURE AND RELEASE AGREEMENT*
Terms and Conditions*
By submitting this form, you (“Client”) acknowledge, understand, and agree to the following terms and conditions regarding the sharing of your personal and financial information with [Your Name / Your Business Name] (“Broker”): 1. Voluntary Disclosure of Information You voluntarily and knowingly consent to providing your personal and financial information, including but not limited to your name, address, date of birth, income, credit information, banking details, and any other information submitted through this form, to the Broker solely for the purpose of facilitating the purchase or acquisition of a motor vehicle on your behalf. 2. Limited Use of Information Your personal and financial information will be used exclusively for the purpose of completing the vehicle transaction for which you have engaged the Broker. Your information will not be sold, transferred, or shared with any third party except as necessary to complete your vehicle purchase (e.g., lenders, dealerships, or title agencies). 3. Destruction of Information Upon the successful completion of your vehicle purchase, the Broker agrees to destroy all copies of your personal and financial information in their possession. You understand and acknowledge that should you wish to engage the Broker’s services again in the future, you will be required to resubmit all personal and financial information at that time, as no records will be retained. 4. Assumption of Risk You understand and acknowledge that the sharing of personal and financial information carries inherent risks, including but not limited to the risk of unauthorized access or data breach. You voluntarily assume all such risks associated with providing your information through this form and any related communications. 5. Release and Hold Harmless Agreement You hereby release, discharge, and hold harmless [Your Name / Your Business Name], and any of their agents, affiliates, or representatives, from any and all claims, demands, damages, losses, liabilities, costs, or expenses of any kind—whether known or unknown—arising out of or in connection with your voluntary submission of personal and financial information through this form or in connection with the brokerage services provided. 6. Waiver of Legal Action To the fullest extent permitted by law, you expressly waive any and all rights to bring any claim, lawsuit, arbitration, or legal action of any kind against [Your Name / Your Business Name] relating to the collection, use, storage, or destruction of your personal and financial information as described in this agreement. 7. Acknowledgment By checking the box below and submitting this form, you confirm that: - You are at least 18 years of age - You have read and fully understand this disclosure - You agree to all terms stated above - Your agreement is given freely, voluntarily, and without coercion I have read, understood, and agree to the above Disclosure and Release Agreement.
By submitting this form, you ("Client") acknowledge, understand, and agree to the following terms and conditions regarding the sharing of your personal and financial information with [Your Name / Your Business Name] ("Broker"): 1. Voluntary Disclosure of Information: You voluntarily and knowingly consent to providing your personal and financial information, including but not limited to your name, address, date of birth, income, credit information, banking details, and any other information submitted through this form, to the Broker solely for the purpose of facilitating the purchase or acquisition of a motor vehicle on your behalf. 2. Limited Use of Information: Your personal and financial information will be used exclusively for the purpose of completing the vehicle transaction for which you have engaged the Broker. Your information will not be sold, transferred, or shared with any third party except as necessary to complete your vehicle purchase (e.g., lenders, dealerships, or title agencies). 3. Destruction of Information: Upon the successful completion of your vehicle purchase, the Broker agrees to destroy all copies of your personal and financial information in their possession. You understand and acknowledge that should you wish to engage the Broker's services again in the future, you will be required to resubmit all personal and financial information at that time, as no records will be retained. 4. Assumption of Risk: You understand and acknowledge that the sharing of personal and financial information carries inherent risks, including but not limited to the risk of unauthorized access or data breach. You voluntarily assume all such risks associated with providing your information through this form and any related communications. 5. Release and Hold Harmless Agreement: You hereby release, discharge, and hold harmless [Your Name / Your Business Name], and any of their agents, affiliates, or representatives, from any and all claims, demands, damages, losses, liabilities, costs, or expenses of any kind — whether known or unknown — arising out of or in connection with your voluntary submission of personal and financial information through this form or in connection with the brokerage services provided. 6. Waiver of Legal Action: To the fullest extent permitted by law, you expressly waive any and all rights to bring any claim, lawsuit, arbitration, or legal action of any kind against [Your Name / Your Business Name] relating to the collection, use, storage, or destruction of your personal and financial information as described in this agreement. 7. Acknowledgment: By checking the box below and submitting this form, you confirm that: - You are at least 18 years of age - You have read and fully understand this disclosure - You agree to all terms stated above - Your agreement is given freely, voluntarily, and without coercion.*
I have read, understood, and agree to the above Disclosure and Release Agreement.*
Signature*
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Vehicle Shopping Client Intake Form

The Auto Broker

Client Information

Vehicle Preferences

Financial Information

Document Uploads

Transaction Type

Warranties & Protections

Credit Range

Timing

Special Notes