Application form Nissan Micra Acenta 0.9 ig-t 90pk/cv 5p

Transcription

1 Worry-free mobility Fixed monthly amount No unexpected costs A reliable new car Application form Nissan Micra Acenta 0.9 ig-t 90pk/cv p Specifications Standard equipment including (included in the lease price) Type of vehicle Fuel Gears Number of doors CO2 emissions (g/km) Consumption/100 km Passenger car Petrol 118 (1),40 l - Audio system (4 LS, USB/iPod connector, bluetooth) - Automatic headlights - Central doorlocking with remote control - Cruise Control with speed limiter - Electrically adjustable, manually folding exterior mirrors - Electric powered front windows - Exterior windows in body colour - Hill Start Assist - Interior upholstery in casual black - LED daytime running lights - Manual air conditioning - Multifunctional steering wheel - Rear bench folding (60/40) - Rear spoiler Number of kw Number of passengers (1) Subject to change Prices (monthly) 66 Options (included in the lease price) - Metallic paint - Rug set Order this car - 16 alloy rims Age of main driver Annual mileage / Duration (per year) km/ 48 months km/ 48 months km/ 48 months < 30 year * 324,- 344,- 364,- 30 year * 314,- 334,- 34,- These prices are valid until stocks are exhausted. *The price difference is due only to the difference in insurance premiums. Includes VAT Insurance (incl. Third-party liability, Casco conditions, Legal Assistance and driver insurance) Alphabet Assistance breakdown service (Belgium and abroad) Repairs, maintenance and tyres Road tax, initial registration tax Replacement car after 24 hours Excludes Fuel, fines, winter tyres Offer valid for all amployees of Alphabet s clients. The illustrations and standard equipment are not contractually binding. Extra options and accessories are unavailable. This configuration cannot be changed. Step 1 Submit your completed application form and questionnaire together with the additional documents to Alphabet Belgium Long Term Rental NV/SA. Step 2 Your request will be processed once this information is received. Orders are always subject to acceptance by Alphabet Belgium Long Term Rental NV/SA. Step 3 If your application is approved the agreement will be drawn up and sent to you. Step 4 Return the signed agreement. Step 14-day cooling-off period once the agreement is signed. Step 6 The car is ordered from the dealer. Step 7 Delivery of car, commencement of lease and start of invoicing. Page 1 of 6

2 Please complete and sign the form below and send it, together with the questionnaire and documents, by to or by post to Alphabet Belgium Long Term Rental NV/SA, attn. My Personal Lease Team, Ingberthoeveweg 6, 2630 Aartselaar. The Alphabet My Personal Lease Team will then contact you. Your car Nissan Micra Acenta 0.9 ig-t 90pk/cv p Type of vehicle Passenger car CO2 emissions (g/km) 118 Fuel Petrol Consumption/100 km,40 l Gears Number of kw 66 Number of doors Number of passengers Your lease Annial mileage / Duration (per year) Age of main driver km / 48 months km / 48 months km / 48 months < 30 year * 324,- 344,- 364,- 30 year * 314,- 334,- 34,- *The price difference is due only to the difference in insurance premiums. * All prices include VAT. Invoicing I wish to receive my invoices electronically (by ) and so take advantage of the 2. discount on the monthly lease rate. I choose to pay by direct debit and so take advantage of the 2. discount on the monthly lease rate. Extra information 386,66: Own risk amount in case of non-recoverable damage (VAT-exempt),76 Eurocents/km (incl. VAT): Price for mileage above or below the end-of-the-contract figure (difference between contractual and actual annual mileage) Car body colour / Interior Car body colour Interior Preferred dealer Address Any further questions? Contact the Alphabet My Personal Lease Team on +32 (0)3/ We will be happy to assist you. Page 2 of 6

3 Your details 1) Applicant/employee data First name Employer Je persoonlijke gegevens in je dossier wijzigen? Stuur een mail naar Gender* Date of birth Language code Street + no. Postcode + town adress Telephone number Mobile phone number* IBAN account no. 2) Partner data (you must fill this in if you are married or legally cohabitating, even if your partner is not the main driver) First name Gender* Date of birth 3) Who is the main driver? (at least 22 years old and holder of a driving licence for 3 years) Applicant/employee Legally cohabitating or married partner Cohabitating partner Family member living in Page 3 of 6

4 4) Details of main driver (must be filled in if different from the applicant/employee and married or legally cohabitating partner) First name Gender* Date of birth ) Applicant/employee income data Contract Please choose Start date for current employer Net professional Other net* (if applicable) 6) Details of partner s income (must be filled in if married or legally cohabitating) Contract Please choose Start date for current employer Net professional Other net* (if applicable) 7) Details of fixed household expenses Living expenses Monthly living expenses (in euros) (If you own the property: monthly mortgage capital and interest repayments) Please choose Other monthly outgoings on current consumer loans (in EUR) (A consumer loan is any loan used for a purpose other than to finance the purchase of real estate: e.g. financing the purchase of a car, electrical household appliances, travel, wedding, etc.) Page 4 of 6

5 8) Other (must be completed) Main driver In the last years have you been convicted of driving under the influence of alcohol or similar substances such as narcotics or drugs? In the last years have you been convicted of the offence of (attempted) hit-and-run? In the last years has your car s insurance policy been cancelled or put forward for adjustment by the insurer of the vehicle? Applicant/employee or partner of the applicant if the applicant is the main driver In the last years have you been convicted of driving under the influence of alcohol or similar substances such as narcotics or drugs? In the last years have you been convicted of the offence of (attempted) hit-and-run? In the last years has your car s insurance policy been cancelled or put forward for adjustment by the insurer of the vehicle? I declare that all the information I have provided is true. I declare that I have read and accept in full the general terms and conditions of Alphabet Belgium Long Term Rental NV/SA. My consent to marketing communication (to be completed by the applicant/employee) I wish to receive information from Alphabet Belgium Long Term Rental NV/SA by , post, telephone/messenger services. Preferred channel of contact Post Telephone/messenger service By checking the above, I accept that Alphabet Belgium Long Term Rental NV/SA, Ingberthoeveweg 6, 2630 Aartselaar, as well as my contract partners and workplaces (e.g. my favourite partner dealer) will process and use the data I have provided for product and service information, as well as for market research and that for these purposes they may exchange my data between them. I am entitled to revoke the consent granted to Alphabet Belgium Long Term Rental NV/SA at any time. This revocation must be communicated to the My Personal Lease team or data protection manager by telephone or (contact.privacy@alphabet.be). I can also use these channels of communication to request information about my data stored by Alphabet Belgium Long Term Rental NV/SA and arrange for my personal data to be corrected, deleted or blocked. More details on the processing of my personal data by Alphabet Belgium Long Term Rental NV/SA are available in the Alphabet Privacy Statement under Page of 6

6 Date: / / Signature of applicant/employee (preceded by Read and approved ) Date: / / Signature of partner (where applicable) (preceded by Read and approved ) Date: / / Signature of main driver (preceded by Read and approved ) Checklist of documents to be provided 1. Copy of identity card of the applicant, her/his partner* and main driver 2. Copy of the main driver s licence 3. Copy of the last two pay slips of the applicant and his/her partner* 4. A bank statement showing the most recent salary payment to the applicant and his/her partner*. A bank statement showing the most recent payment of living expenses (rent or mortgage) 6. Copy of the applicant s tax assessment (personal income tax) for the most recent assessment year 7. If you have any additional sources of monthly income please enclose evidence of these 8. History of claims by the main driver (to be requested from the insurance company and covering at least the last 3 years) * Applicable if you are married or legally cohabitating (compulsory) or if your partner wishes to sign the contract. Alphabet Belgium Long Term Rental NV (Alphabet Belgium) Ingberthoeveweg Aartselaar Company number RLP Antwerp, Antwerp Division Page 6 of 6