Secure Loan Application

Primary Borrower Information

Loan Information

Desired Loan Amount:

Desired Monthly Payment:

Personal

First Name:

Middle Initial:

Last Name:

Address:

City:

State:

Zip:

Daytime Phone:

Evening Phone:

Fax:

- -

Email:

Social Security Number:

- -

Birthday:

/ /

Mortgage/Rent Payment:

per month

Residence Type:

Time at Residence:

Years

Time at Residence:

Months

If you have lived at your current residence less than 5 years, please enter your prior address:

Which accounts are in your name:

Utilities Savings Checking Phone

Drivers Lic. #:

Drivers Lic. State:

(CA,NY, etc.)

Driver Lic. Exp. Date:

(MM/DD/YYYY)

Employment

Employer Name:

Employer Address:

Employer City:

Employer State:

Employer Zip:

Business Phone:

Occupation:

Employment Status:

Time On Job:

Years

Time On Job:

Months

How often are you paid:

How much per paycheck:

(numbers only)

Other Income:

per month

Consent:

I agree that by submitting this application, I authorize and give this dealership, as well as any potential financing source this dealership presents this application to, my consent to obtain my credit report from any credit reporting agency used to complete an investigation of my credit.

Vehicle Information

Vehicle Make:

Vehicle Model:

Vehicle Year:

Vehicle Mileage:

Down Payment

Down Payment Amount:

Trade-In Details

Trade-in Make:

Trade-in Model:

Trade-in Year:

Trade-in Mileage:

Additional Comments:

Acknowledgement:

Your privacy is important to us. To better protect your privacy, we provide this notice explaining our online information practices and the choices you can make about the way your information is collected and used. This notice applies to all information collected or submitted on the Automotive Connection website. The only personal information we collect is name, street and email address, telephone number, credit card information, social security number and employment information. We use the personal information collected from you to process applications. Such personal information as we collect is not used for any other purpose and is not shared.

Co-borrower Information

Personal

First Name:

Middle Initial:

Last Name:

Address:

City:

State:

Zip:

Daytime Phone:

Evening Phone:

Fax:

- -

Email:

Social Security Number:

- -

Birthday:

/ /

Mortgage/Rent Payment:

per month

Residence Type:

Time at Residence:

Years

Time at Residence:

Months

If you have lived at your current residence less than 5 years, please enter your prior address:

Which accounts are in your name:

Utilities Savings Checking Phone

Drivers Lic. #:

Drivers Lic. State:

(CA,NY, etc.)

Driver Lic. Exp. Date:

(MM/DD/YYYY)

Employment

Employer Name:

Employer Address:

Employer City:

Employer State:

Employer Zip:

Business Phone:

Occupation:

Employment Status:

Time On Job:

Years

Time On Job:

Months

How often are you paid:

How much per paycheck:

(numbers only)

Other Income:

per month

Consent:

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.

Automotive ConnectionSecure Loan Application

Primary Borrower Information

Loan Information

Personal

Employment

Vehicle Information

Down Payment

Trade-In Details

Co-borrower Information

Personal

Employment

Automotive Connection
Secure Loan Application