Chrysler Dodge Mopar, International Trucks | Auto Sales, Service, Parts, Collision Repair

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Single Credit Application

Be assured that the information you submit is kept secure and confidential.
* In order to process a quick response please input data in all fields that apply

What vehicle are you interested in?

Preferred Salesman:

Year:

Make:

Model:

Personal Information (Primary Applicant)

First Name:

Middle:

Last Name:

Address:

City:

State:

Zip:

Time at current residence:

Years:

Months:

If at current residence for less than 2 years, please provide previous address:

Previous Address:

City:

State:

Zip:

Day Phone:

Evening Phone:

Cell Phone:

Fax:

Email:

Date of Birth:

Month:

Day:

Year:

Social Security Number:

Driver's License Number:

State:

Dwelling Information

Please Check one of the following:

Own/ Buying home

Leasing/ Renting

Living with Relative or Friend

Name of Landlord or Mortgage Holder:

Address of Landlord or Mortgage Holder:

Rent or Mortgage Monthly Payment

Education

Education Level:

Bachelor's Degree

Associate's Degree

Special Training or Trade School

Currently a College Student

High School Graduate

Employer Information

Current Employer:

Address:

City:

State:

Zip:

Employer Phone:

Current Position:

Time at current job:

Years:

Months:

Gross Annual Income (before taxes):

Other Income:

Source of Other Income:

If at current job for less than 2 years, please provide previous employment:

Previous Employer:

Address:

City:

State:

Zip:

Employer Phone:

Position Held:

Time at previous job:

Years:

Months:

Gross Annual Income (before taxes):

Banking Information

Name of Bank:

Please check all that apply:

Checking and Savings

Checking Only

Savings Only

Other

None

Do you have any current auto loans?

Yes

Name of Creditor:

Date Opened:

Amount Borrowed:

Monthly Payment:

Current Unpaid Balance:

Will this vehicle be a trade-in?

Yes

Have you had any previous auto loans?

Yes

Name of Previous Creditor:

Date Opened:

Amount Borrowed:

Monthly Payment:

Date Closed:

Have you ever had a vehicle or other item repossessed?

Yes

If yes, date of repossession:

Have you ever filed for bankruptcy?

Yes

Has the bankruptcy been discharged?

Yes

If yes, date of discharge:

Fair Credit Reporting Act Disclosure

By submitting this application, I understand you will be checking with credit reporting agencies and that the information provided by me is complete and accurate to the best of my knowledge. I also understand I may request in writing within a reasonable time a full disclosure report. Though this application will be forwarded to available financial institutions, I understand this does not obligate me in any way to use their financing source(s).

Privacy Notice

In connection with your transaction we may obtain nonpublic personal information about you and that information is handled as stated in this notice.

1. We collect personal nonpublic information about you from the following sources:

• Information we receive from you on applications or other forms;
• Information about your transactions with us, our affiliates or others; and,
• Information we receive from a consumer reporting agency.

2. We may disclose all the information we collect, as described above, to companies that perform marketing services or other functions on our behalf or to other financial institutions with whom we have joint marketing agreements.

3. We may also disclose nonpublic personal information about you, as a consumer, customer or former customer, to non-affiliated third parties as permitted by law.

4. Further, we restrict access to your nonpublic personal information to only those employees who need to know that information to provide products or services to you. Employees cannot use your information for any other purpose. For your protection, we maintain physical, electronic and procedural safeguards that comply with federal regulations.

By clicking Submit you agree to the above statement and allow Sternberg, Inc. to check your credit. If you choose not please click Reset.