Contact Info

First Name*

Last Name*

Email Address*

Phone #*

Street Address*

Address line 2

City*

State*

Zip Code*

Date of Residency

This is the date you started living at your current residence

Monthly Rent/Mortgage

Social Security #*

Date of Birth*

Employment info

Employer Name*

Employer Phone #

Gross Monthly Income*

Additional Income

Date of Employment

Tell us about the vehicle you want

Total Loan Amount*

How should we contact you?*

I agree to give permission for the above applicant(s) Consumer Credit Report(s) to be obtained, at no cost to me, in order to help determine the types and extent of financing which are available*

[Optional] I consent to receiving telemarketing calls or texts at this number using an automatic telephone dialing system by, or on behalf of, Genesis and its authorized dealers. I understand I do not have to consent in order to submit a lead, receive contact from the dealer, or purchase any products or services. Carrier charges may apply. By submitting your information, you agree to the sharing of your information between Genesis of Puerto Rico and its authorized dealership.

^{By submitting your information, you agree to the sharing of your information between Genesis of Puerto Rico and its authorized dealership.}

^{In connection with your transaction, Genesis of Puerto Rico may acquire information about you as described in this notice, which we handle as stated in this notice.}

^{We may collect personally identifiable information such as name, postal address, telephone number, e-mail address, social security number, date of birth, etc. This personal information is collected and used by Genesis of San Juan Financial & Insurance staff for the purpose of facilitating a relationship or business transaction.}

^{Our website resides behind a firewall and uses SSL (Secure Sockets Layer, the industry-standard security protocol used to communicate with browsers) to transmit personal information. Data is strongly encrypted during transmission to ensure that personal and payment information is secure. Industry-standard data encryption techniques are used to protect personal information.}

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