APPLICANT

BASIC INFORMATION
NAME (First, Middle Initial, Last)   # IN FAMILY Married Separated Unmarried (Single, Divorced, Widowed) US CITIZEN  Yes    No
DATE OF BIRTH mm/dd/yy   SOCIAL SECURITY #   DRIVERS LICENSE #  
CURRENT ADDRESS (Street, City, State & Zip Code) - (Street address MUST be shown)
 
CURRENT MAILING ADDRESS (If Different) Same format as above
 
How Long at Current Address (years/months)    Rent or Own Monthly Payment   $ HOME TELEPHONE #  
PREVIOUS ADDRESS (Street, City, State & Zip Code) - If less than 2 years at Current Address
 
How Long at Previous  Address (years/months)    Rent or Own Monthly Payment   $ CELL TELEPHONE #  

RELATIVES
NEAREST RELATIVE NOT LIVING WITH YOU (NAME)   RELATIONSHIP   RELATIVE TELEPHONE #  
RELATIVE'S ADDRESS (Street, City, State & Zip Code
 

EMPLOYMENT
EMPLOYER'S NAME   HOW LONG EMPLOYED?  Months/Years   OCCUPATION  
EMPLOYER'S ADDRESS (Street, City, State & Zip Code)
 
GROSS MONTHLY INCOME $ SELF-EMPLOYED Yes or  No BUSINESS TELEPHONE #  
PREVIOUS EMPLOYER'S NAME   PREVIOUS HOW LONG EMPLOYED?  Months/Years   PREVIOUS EMPLOYER TELEPHONE #  
PREVIOUS EMPLOYER'S ADDRESS (Street, City, State & Zip Code)
 

CO APPLICANT

BASIC INFORMATION
NAME (First, Middle Initial, Last)   # IN FAMILY Married Separated Unmarried (Single, Divorced, Widowed) US CITIZEN  Yes    No
DATE OF BIRTH mm/dd/yy   SOCIAL SECURITY #   DRIVERS LICENSE #  
CURRENT ADDRESS (Street, City, State & Zip Code) - (Street address MUST be shown)
 
How Long at Current Address (years/months)    Rent or Own Monthly Payment   $ HOME TELEPHONE #  

EMPLOYMENT
EMPLOYER'S NAME   HOW LONG EMPLOYED?  Months/Years   OCCUPATION  
EMPLOYER'S ADDRESS (Street, City, State & Zip Code)
 
GROSS MONTHLY INCOME $ SELF-EMPLOYED Yes or  No BUSINESS TELEPHONE #  

PAGE 1 OF 3 CREDIT APPLICATION






OTHER INCOME
OTHER NET MONTHLY INCOME: You do not have to reveal alimony, child support or separate maintenance income unless you wish to have them considered for approving your application.
SOURCE:    AMOUNT:
Have you ever had any property reposed? Yes or No
Do you have any lawsuits pending against you? Yes or No
Have you ever filed Bankruptcy? Yes or  No

Instructions to Married Applicant (s): Answer all questions relating to you. Also answer all questions relating to your spouse unless you are separated and your spouse is not also applying for credit. All income and properly will be assumed to be community properly and all obligations will be assumed to be community debts unless 'SP' is written next to the income, property or debt.

Each applicant may apply for individual or joint credit, regardless of marital status. This application is for:
Individual Credit  -  Joint credit with the applicant's spouse  -  Joint credit with whose separate credit application is attached.

Notice For New York Residents - A consumer credit report may be requested in connection with this application or in connection with updates: renewals or extensions of any credit granted as a result of this application. If you subsequently ask for this information, you will be informed whether or not such a report was requested and, if so, the name and address of the agency that furnished the report

Notice for Ohio Residents - The Ohio laws against discrimination require that all creditors make credit equally available to all credit worthy customers, and that credit reporting agencies maintain separate credit histories on each individual upon request. The Ohio Civil Rights Commission administers compliance with this law.

Notice to Married Wisconsin Residents - Wisconsin Law provides that no agreement, unilateral statement or court decree relating to marital property shall adversely affect a creditor's interest, unless prior to the time credit is granted the creditor is furnished a copy of the agreement, statement or decree or has actual knowledge of the adverse provision. You must indicate the name of your spouse on the installment contract, and the address if different from yours.

Notice to California and Utah Residents - As required by law, you are hereby notified that a negative credit report reflecting on your credit record may be submitted to a credit reporting agency if you fail to fulfill the terms of your credit obligations.

Notice for Marine Residents - If this application is approved by the creditor, you will be required to obtain and maintain physical damage insurance on collateral securing the debt. You have a right of free choice in the selection of the agent and insurer through or by which the insurance is placed.

I hereby affirm that the foregoing information is true and correct and made for the purpose of obtaining credit. I authorize you to obtain additional information from any source (s) and each such source is hereby authorized to provide you with such information. I also grant you permission to obtain a credit report on me for all legitimate purposes in connection with this transaction. Such purposes include assisting in making a credit decision, reviewing my account, and assisting in taking collection activity. I also authorize you to share all the foregoing information with with lending institutions and their subsidiaries as necessary to assist in making a credit determination. This application, in any event, shall be and remains the property of the Lender, and is subject to the completion and acceptance of additional credit application documents prior to any approved extensions of credit.

Applicant _______________________________________________________ Date ___________

 

Co-Applicant _____________________________________________________ Date ____________

Applicant (s) acknowledges receipt of completed copy of application.

Applicant (s) acknowledges receipt completed copy of application.

PAGE 2 OF 3 CREDIT APPLICATION



Please Fax or Mail to:

Venice Dodge Mobility
ATTN: Richard Miller Mobility Manager
50 US 41 Venice Bypass South, Venice, FL 34292
Toll Free: 866-400-3443
Local: 941-468-3443
Fax: 941-484-1390
Ask For: Richard Miller - Mobility Manager

PAGE 3 OF 3 CREDIT APPLICATION