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Secure Credit Application

Fields in blue are required

Credit Application Type
Loan Information
Purpose of loan
Loan amount requested
Desired # of monthly payments
Desired monthly payment
Amount Down
VIN of trade-in
# Miles on trade-in
Amount owed on trade-in
Applicant's Personal Information
Full Name
   
Marital Status
Social Security #
- -
Driver's License #
Driver's License Exp Date
Date of Birth
Email Address
Home Phone
Cell Phone
Applicant's Current Address
Street 1
Street 2
City / State / Zip
How long have you lived here?
Residence Status
Have you lived here more than 5 years?
Have you lived here more than 5 years?
   
Applicant's Previous Address
Street 1
Street 2
City / State / Zip
How long have you lived here?
Applicant's Financial Information
Current Bank
Bank's Address
Check all that apply
               
Previous Bankruptcy?
Previous Bankruptcy?       
Pending Bankruptcy?
Pending Bankruptcy?       
Applicant's Current Employer
Employer Name
Job Title
Phone Number
How long have you been there?
Gross annual income
Applicant's Previous Employer
Employer Name
Job Title
Phone Number
How long have you been there?
Applicant's Additional Income
Additional Monthly Income
Additional Annual Income
Co-Applicant's Personal Information
Full Name
   
Relationship to Applicant
Social Security #
- -
Driver's License #
Driver's License Exp Date
Date of Birth
Email Address
Home Phone
Cell Phone
Co-Applicant's Current Address
Street 1
Street 2
City / State / Zip
Date you started living here
Residence Status
Have you lived here more than 5 years?
Have you lived here more than 5 years?
yes     no
Co-Applicant's Previous Address
Street 1
Street 2
City / State / Zip
How long have you lived here?
Co-Applicant's Financial Information
Current Bank
Bank's Address
Check all that apply
               
Previous Bankruptcy?
Previous Bankruptcy?       
Pending Bankruptcy?
Pending Bankruptcy?       
Co-Applicant's Current Employer
Employer Name
Job Title
Phone Number
Date you began working there
How long have you been there?
Gross annual income
Co-Applicant's Previous Employer
Employer Name
Job Title
Phone Number
How long have you been there?
Co-Applicant's Additional Income
Additional Monthly Income
Additional Annual Income
Financial Debts / Obligations
Type of Debt
Holder
Balance
Payment (mo/wk/etc)
Personal References
Relationship
Name
Phone
Address (City/State)

to authorize us to share your nonpublic personal information with affiliated and/or nonaffiliated third parties. I understand that in checking this that you may be better able to serve me and that I may receive offers for other products and services that may be of value to me. Please read our privacy policy for more information regarding your rights and how we use the personal information you submit to us.

FAIR CREDIT REPORTING ACT DISCLOSURE:

This application for credit may be submitted by the Dealer to various financial institutions. Before this application is submitted, the Dealer will disclose to you the name and address of the institution(s) who will receive copies of this application.

By clicking on the 'submit' button below I certify that the above entered information to be true and correct and I hereby authorize you to use this information to perform a credit rating check of my personal credit. I also certify that I am over the age of 18 and am a current U.S. citizen or permanent resident. In addition, I understand that submitting the above information does not represent an obligation by any party to provide credit nor does it obligate me to accept any credit offered.

Haz-M Automotive
307 S Main Street
New Lexington, OH 43764
(740) 342-5239
HOURS
Monday By Appointment
Tuesday 2:00PM - 6:00PM
Wednesday 2:00PM - 6:00PM
Thursday By Appointment
Friday 9.00AM - 2 PM
Saturday By Appointment
Sunday Closed