128-bit Secure Credit Application

Required Fields are indicated in bold.

Applicant Information

First Name:	*	Social Security Number:	* * example 123-45-6789
Middle Name:		Date of Birth:	* * example 12/31/1960
Last Name:	*	Drivers License Number:	*
eBay User Id: (Leave blank if not applicable)		Drivers License State:	*

Address Information

Address:

Residence: *

Rent

Own

Other

Address Continued:

PO and APO boxes are not valid

Rent/Mortage:

City:

Time at Residence: *

Years: Months: *

State:

Have you filed bankruptcy? *

Yes

Zip:

* *

Home Phone: * *

example 212-555-1234

Email Address:

* *
Use a valid email address

Cell Phone:

example 212-555-1234

Employment Information

Employer:	*	Position:	*
Length of Employment:	Years: Months: * *	Work Phone Number:	* example 212-555-1234
Gross Monthly Income:	* *	Other Income:	*
Source(s) or other income: alimony, child support or separate maintenance income need not be disclosed if you do not wish to have in considered as a basis for repaying this obligation.

Previous employer if less than 5 years at current employer

Employer:		Position:
Work Phone Number:	example 212-555-1234	Length of Employment:	Years: Months:

Do you have a co-signer?	Yes

CALIFORNIA RESIDENT: Applicant, if married, may apply for a separate account. MAINE, RHODE ISLAND, AND TENNESSEE RESIDENTS: You must have physical damage insurance covering loss or damage to the vehicle for the term of any contract. For a lease, you must also have the liability insurance as described in the lease. You may buy this insurance from anyone you choose. You do not have to buy it from or through someone affiliated with the dealer or an assignee of this contract. Your choice of insurance will not affect the credit approval process unless the insurance does not satisfy the contract requirements or the insurance company does not satisfy the reasonable standards of the dealer or an assignee of the contract. NEW HAMPSHIRE RESIDENT: If you are applying for a balloon payment contract, you are entitled, if you ask, to receive a written estimate of the monthly payment amount for refinancing the balloon payment in accord with the creditor’s existing refinance programs. You would be entitled to receive the estimate before you enter into a balloon payment contract. A balloon contract is an installment sale contract with a final scheduled payment that is at least twice the amount of one of the earlier scheduled equal periodic installment payments. NEW YORK RESIDENT: Consumer reports may be requested in connection with this application. Upon your request, you will be informed as to whether or not a consumer report was requested and informed of the name and address of the consumer reporting agency that furnished the report. On any update, renewal or extension of this credit, subsequent consumer reports may be requested. OHIO RESIDENT: The Ohio laws against discrimination require that all creditors make credit equally available to all creditworthy 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. By signing this application: 1. I authorize Dealer and any finance company, bank, or other financial institution to which the Dealer submits my application ("you" or "your") to investigate my credit and employment history, obtain credit reports, and release information about your credit experience with me as the law permits. 2. If an account is created, I authorize you to obtain credit reports for the purpose of reviewing or taking collection action on the account, or for other legitimate purposes associated with the account. 3. I certify that I have read and agree to the terms of this application and that the information in it is complete and true. 4. I authorize you to start a credit investigation based on the information voluntarily provided by me which is true and correct, and reflects all my current debts. In addition, I authorize you to obtain federal and state records of employment and income history, including State Employment Security Agency ("SESA") records. This SESA authorization is for this transaction only and continues in effect for one (1) year unless limited by state law, in which case the authorization continues in effect for the maximum period, not to exceed one (1) year, as allowed by law. A bankruptcy proceeding is not in progress nor expected. If the attached application is submitted in the same name of a business, a current and year-end financial statement, including P&L statement, and balance sheet may be required, audited if possible. I / We certify that everything stated on this application is true and correct to the best of my / our knowledge.