Mascoma Auto INC
Secure Loan Application

Primary Borrower Information

Vehicle Applying for

Applicant Information

Physical Address

Mailing Address

How long at present address?

$

Previous Address

years/months

Phone

Social Sec #

- -
/ /

Employment

(numbers only)
/ /
/ /

Previous Employer

Source of other Income

Other Monthly Income

Personal References

- -

Bank Information

$

Please list any and all Outstanding Debt Accounts or Credit References

Consent

I certify that the above information I have provided Mascoma Auto, Inc. is true and accurate to the best of my knowledge and I have Voluntarily provided this information in order to induce Mascoma Auto, Inc. to sell me a used automobile by weekly installment payments.

Applicant Signature

(Add your Initials please)
/ /

By submitting this application, I certify that all information herein is true and complete. I agree I am providing this information to the dealer identified in this application and acknowledge that my information may be shared pursuant to the dealer’s privacy policy, if applicable. I hereby authorize this dealer, and any financial institution engaged as a service provider by this dealer, to retain this application and to check and verify my credit, employment and salary history. By submitting this application, I acknowledge I am authorizing this dealer to check my credit.