Dealer  
  
Date  

Merchandise purchased  
        
App.type(I or J)  
   
Sales person handled by:
 
Cash Price  

Cash down  
        
Trade-In 

Amount Requested  

No. of months  




Follow-up / Comments 

PERSONAL

Purchaser(1) title 
(first name ,  initial. ,last name)  
  
Purchaser(2) title
(first name ,  initial. ,last name)  

Marital Status 
Married  Since______
UnmarriedSeparated
number of dependants
(except spouse)
-if paying child support,
alimony,or child 
care, list below in 
accounts outstanding.

Birthdate(1)
 
Social security number(1)  

Birthdate(2)
 
Social security number(2)  


PRESENT ADDRESS

street   box   RR

City State Zip

Date of address(month/year) 

Phone  

County  

Years in state/area  

HOUSING STATUS
not-a-home-buyer-or- owner
buying or own a house
Purchase price of home 

Current Value  

Balance Owing 

Down payment  

monthly payment/rent  

Mortgage company/landlord 

PRESENT EMPLOYMENT-purchaser1
Employer

Position 

Department

Employer Address

Date employed  (month  year)

Gross monthly income

Net monthly income

Phone

Comments 



PRESENT EMPLOYMENT-purchaser2
Employer

Position 

Department

Employer Address

Date employed  (month  year)

Gross monthly income

Net monthly income

Phone

Comments