* Required Field  
Application Primary

Applicant

First Name MI Last Name  
Date of Birth Social Security #  
Marital Status
Driver's License # State Exp. Date
Phone Cell Email

Current Address

Address Line 1
Address Line 2
City State Postal Code
How long at this residence: Years Months
Are you
Are you on the lease or mortgage?
Who do you live with?
If leasing is it?
Landlord/Mortgage Holder
Landlord/Mortgage Holder Phone #/Account #
This is a
What is your monthly rent or mortgage payment? Is the payment current?

Previous Address
(if less than 1 year)


Mailing Address
(if different from above)


Residence Continued

How long have you lived in this area?
How many residence changes have you had in the last 5 years?

Employment

Employer Hire Date
Address Line 1
Address Line 2
City State Postal Code
Work Phone
Supervisor Name Your Job Title - Position
Are you paid hourly or salary?    Amount?
How often are you paid?
What is your pay after taxes? $
What day of the week is payday on?
How many hours do you work a week?
Miles to work, one-way?

Former Employment
(If less than 1 year)


Other Income

Do you have a part-time job?
Employer Address
Net Pay Monthly

Other sources of income? *
* (Spousal income, child support, or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.)

Net Monthly Income from Other Sources

Banking Accounts

Checking Account No. And Bank
Savings Account No. And Bank

Current Vehicle

What vehicle do you drive now?
Is it paid for?   Financed by?
Please list all additional drivers
Have you ever had a vehicle repossessed in the last 12 months?
How many?   Last car repossessed by? When?

Bankruptcy

Have you ever filed for bankruptcy in the last 12 months?
When? What is the status of any bankruptcy proceeding?
Are you contemplating bankruptcies, or visited an attorney about filing for bankruptcy?

Other

Are you in the military?
Are you   and What branch?
The vehicle I am purchasing is for
The vehicle I am purchasing is for   Who?

Primary Applicant Personal References

Name Relation
Address
City State Postal Code
Phone Years Known

Name Relation
Address
City State Postal Code
Phone Years Known

Name Relation
Address
City State Postal Code
Phone Years Known

Name Relation
Address
City State Postal Code
Phone Years Known

Name Relation
Address
City State Postal Code
Phone Years Known


Please Check * I, the Applicant, certify that all of the statements in this application are true and complete and are made for the purpose of obtaining credit.
 

 

Do you Have a Co-Applicant? (co-buyer, co-signer) Yes No

Questions / Comments?


POLICY
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Applicant's Signature *  x

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I have read and accept the above policy.


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