* Required Field

Applicant's Information

First Name *		MI	Last Name *
E-Mail *		Phone *		Fax
Birth Date *		Social Security # *
Mother's maiden name		* Single Married Separated
Driver License Number *		State of Issue * Expiration date *
US Citizen *	Yes No

Primary Residence

Address Line 1 *
Address Line 2
City *	State * Postal Code *

Amount of Time at this Residence: Years * Months * Type of Residence * Own Rent Other

Total monthly housing payment * $		Total years as a homeowner

Previous Residence
(If less than 2 years at current residence)

Mailing Address
(If different than primary address)

Nearest Relative (not living with you)

Name *
Address Line 1 *
Address Line 2
City *	State * Postal Code *
Phone Number *	Relationship *

Current Employment

Occupation	Employer
Payment Type	Hourly Salary Other
Hire Date
Work Phone
Self-Employed?	Yes No
Gross Monthly Income $	Monthly
How long employed by this employer? Years Months
Address Line 1
Address Line 2
City	State Postal Code

Previous Employment
(If less than 2 years at current employment)

Financials

Other Monthly Income $
Please list other income sources

Checking Account? *	Yes No / Current Balance * $
Savings Account? *	Yes No / Current Balance * $

Bank Name

Do you receive or pay child support? * No Receive Pay

Other liquid assets $
Please list other liquid asset sources

Are you in the middle of a bankruptcy? * Yes No

Have you filed for bankruptcy in the last 5 years? * Yes No

Net Income (or take home money per month) *

Please Check * I, the Applicant, certify that all of the statements in this application are true and complete and are made for the purpose of obtaining credit.

Do you Have a Co-Applicant? (co-buyer, co-signer) Yes No

Do you have a vehicle you plan to trade in? Yes No

Loan Details

If you are unsure of the details of your loan then a representative will contact you to aid you in completion of this or any section that you request.

Check Here If you would like a representative to contact you.

Vehicle To Be Purchased

Seller: Select Motors, 603 Amelia Street, Plymouth, MI phone: 800-634-8370
Link: autos.php?te_class=autos&te_mode=view&te_key=1241

ListingID		LocationID		License Number		Stock Number

VIN

Mileage

Make

Model

Model Year

Down Payment * $		Total Vehicle Cost * $
Payment Amount * $

Questions / Comments?

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(you are required to read this)

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