Personal Information

Your Name

Date of Birth

SSN

Phone Number

Street Address

City

State

Zip Code

Your Email

Employer Information

Employer Name

Gross Monthly Income

FAIR CREDIT REPORTING ACT TO CONSUMER

THIS WILL ADIVSE YOU THAT YOUR RETAIL INSTALLMENT SALES CONTRACT AND BUYER’S APPLICATION FOR SECURED DEBT WILL BE SUBMITTED TO FINANCIAL
INSTITUTIONS AND THEIR AFFILIATES FOR PURCHASE AND CONSIDERATION AS TO WHETHER YOU MEET THEIR CREDIT REQUIREMENTS.

THE UNDERSIGNED FURTHER AUTORIZES THESE FINANCIAL INSTITUTIONS AND THEIR AFFILIATES TO OBTAIN SUCH INFORMATION THAT THEY MAY REQUIRE IN
ORDER TO VERIFY INFORMATION RELATIVE TO THIS REQUEST INCLUDING CONTACTING SPOUSES TO VERIFY SPOUSE RELATED INFORMATION.

I CERTIFY THAT ALL INFORMATION GIVEN BY ME ON THIS APPLICATION IS COMPLETE AND ACCURATE. I GIVE MY PERMISSION FOR ANY FINANCIAL INSTITUTION
WHICH WILL REVIEW THIS CREIDT APPLICATION, TO INVESTIGATE MY CREDIT AND EMPLOYMENT HISTORY, AND TO ANSWER QUESTIONS ABOUT THEIR CREDIT
EXPERIENCE WITH ME INCLUDING BUT NOT LIMITED TO LATE PAYMENTS, MISSED PAYMENTS OR OTHER DEFAULTS, AND THIS INFORMATION MAY BY REPORTED
IN YOUR CREIDIT REPORT.

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