Gregg Smith :: Finance

Mouseover...

Have you talked

with one of our associates? If so, who?

Associate:

*Your Name

First and last, please

*Address

City

State

Zipcode

*Daytime Phone

numbers only, with area code please

preferred

* Evening Phone

numbers only, with area code please

preferred

* Cell Phone

numbers only, with area code please

preferred

*E-mail

preferred

*Date of Birth

mm/dd/yyyy

*Social Security Number

*Time at Residence

Years, Months

*Do You

Own Rent Other

*Rent/Mortgage

numbers only, please

If you have lived at your
current residence less than 2 years:

*Previous Address,
City, State Zip

*Time at Previous Residence

Years, Months

Employment

*Employer's Name

*Employer's Address,
City, State Zip

*Phone Number

include area code, please: xxx-yyy-zzzz

*Occupation

*Time on Job

Years, Months, Weeks

*Monthly Income

*Additional Monthly Income

*Source of Additional Income

If you have worked at your current employment less than 2 years:

*Previous Employer's Name

*Previous Employer's Address,
City, State Zipcode

*Phone Number

include area code, please: xxx-yyy-zzzz

*Occupation

*Time on Job

Years, Months, Weeks

References

1.	Name	Address	City, State Zip

	Phone Number	Years Known	Relationship

2.	Name	Address	City, State Zip

	Phone Number	Years Known	Relationship

Important Info: Please Read!

I authorize Dealer ("you" and "your") and any finance company, bank, or other financial institution to which the Dealer submits my application to investigate my credit and employment history, obtain credit reports, and release information about your credit experience with me as the law permits.

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.

* I certify that I have read and agree to the terms of this application and that the information in it is complete and true.