This form will help us deliver the car you want, in the time frame you want and at a great deal.

1) Describe the Vehicle you want to Purchase

Year Range



Engine Size

Transmission Type

List any Factory Fitted Options/Packs you would like:

Which of the following would you like on your next car?


Are there other Brands with similar models you want to consider?

How do you intend to pay for your next car?

If you're considering a loan of any type:

This car will be used for:

Monthly Payment Range:



When do you want to take delivery of your next car?

What is Best Time to call you to discuss this further?

2) Your Information

Name of Purchaser*

Name of Business (if applicable)


Post Code*

Contact Number*

Your Email*

Car Purchase Type

Do you have a trade-in vehicle?

If NO, skip to bottom.

Is the trade-in currently under finance?

Name of Finance Co

Account Number

Current Payment (per month)

Describe your trade-in vehicle:




Engine Size

Transmission Type


List any Factory Fitted Options/Packs fitted


Comments about your trade-in:

Brokerage WA want zero money upfront. We will do the work on good faith. If you prefer we can charge the dealer for your fee and have it included in the purchase price.

Thank you for your briefing. We will be in contact shortly or as per your nominated time.

I confirm this Application as my appointment of Brokerage WA as my buyers advocate for the purchase as detailed above. I am ready to make this purchase and in appointing Brokerage WA acknowledge they will do the work necessary and I will make all enquiries through Brokerage WA. I understand there is no obligation to accept any tendered price and the final decision to purchase is mine only. In the event of Brokerage WA completing all work up to point of decision that should I then decide not to proceed Brokerage WA may charge 50% of their base fee. I am over 18 years of age and have full authority to enter into this Broker Agreement.