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Dealer: (812) 865-4820

FAX: (812) 865-2192

Dealer Credit Application

APPLICANT
* indicates required field

*Birthdate

*Address (No. St.) Need Min. 3 Yrs. History
*City
*State
*Zip Code
*How Long (yrs/mos)




Balance Owed
$
Monthly Payment
$
Mtg. Holder/Landlord
*Home Tele. No.
(
Previous Address (No. St.)
City
State
Zip Code
How Long (yrs/mos)
NOTICE - Alimony, child support or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.
*Employer - Need Minimum 3 Years History
*Occupation
*Office Tele. No.
( )
*Gross Monthly Pay
$
*How Long (yrs/mos)
Previous Employer
Occupation
Office Tele. No.
( )
Gross Monthly Pay
$
How Long (yrs/mos)
Other Monthly Income
$
Source of Other Income
Bank Reference



Nearest Relative

*Name
*Address
*Telephone No.
( )
JOINT APPLICANT (Co-Makers Must Complete Separate Application)

Birthdate

Address (No. St.) Need Min. 3 Yrs. History
City
State
Zip Code
How Long (yrs/mos)




Balance Owed
$
Monthly Payment
$
Mtg. Holder/Landlord
Home Tele. No.
(
Previous Address (No. St.)
City
State
Zip Code
How Long (yrs/mos)
NOTICE - Alimony, child support or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.
Employer - Need Minimum 3 Years History
Occupation
Office Tele. No.
( )
Gross Monthly Pay
$
How Long (yrs/mos)
Previous Employer
Occupation
Office Tele. No.
( )
Gross Monthly Pay
$
How Long (yrs/mos)
Other Monthly Income
$
Source of Other Income
Bank Reference



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