Application For Financing:

First Name*

Last Name*

Middle

Email*

Birth Date M/D/Y*

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Social Security #*

Home Street Line 1*

City/State/Zip*

AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NC ND NJ NM NY OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Residence Owned By*

Self Or Spouse Self w/Mortgage Relative Landlord Military

Since: Month/Year*

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 20242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927

Monthly Payment*

Bank Name: Checking*

Bank Name: Savings

Drivers License

Phone Cell*

Phone Home

Primary Phone

Home Cell Work

Gross Pay Monthly*

Hire Date At Current Job*

Income Type:*

Employee (Gets W-2) Self-Employed (No W-2) Fixed Income (Net) Temp Service Employee Unemployed

Employer

Job Title

Work Phone

Employer Address

City/State/Zip

Salesperson/Down/Trade

How did you hear about us?

Cosigner:

Agreed To*:

ACKNOWLEDGMENT AND CONSENT:
I certify that the above information is complete and accurate to the best of my knowledge. Creditors receiving this application will retain the application whether or not it is approved. Creditors may rely on this application in deciding whether to grant the requested credit. False statements may subject me to criminal penalties. I authorize the creditors to obtain credit reports about me on an ongoing basis during this credit transaction and to check my credit and employment history on an ongoing basis during the term of the credit transaction. If this application is approved or declined, I authorize Peoples Choice Auto Inc. to give credit information about me to its affiliates.