CREDIT APPLICATION

NORTHERN STATE AUTO, INC. 607-734-3752 FAX 607-734-1031
CREDIT APPLICATION
* Required Fields - Please Print Legibly
TODAY'S DATE & TIME

MonthDayYear
Date
APPLICANT INFORMATION:
SOCIAL SECURITY NUMBER*
FIRST NAME*
M.I.*
LAST NAME*
ADDRESS*
TIME AT RESIDENCE -YEARS*
MONTHS AT RESIDENCE
CITY*
STATE*
ZIP CODE*
DAY PHONE*
CELL PHONE
EMAIL(OPTIONAL
example@example.com
PREVIOUS ADDRESS (IF LESS THAN 3 YEARS)
How LONG
BIRTHDATE (MM/DD/YYYY)*

MonthDayYear
Date
LICENSE #/STATE*
FAMILY
OWN
RENT
OTHER
MORTGAGE/RENT PAYMENT*
EMPLOYER/RETIRED/SOCIALSECURITY ETC*
Address*

* ADDRESS

Street Address Line 2

* CITY/STATE/ZIPState / Province

Postal / Zip Code
OCCUPATION*
EMPLOYER PHONE NUMBER*
TIME ON JOB - YEARS*
TIME ON JOB - MONTHS
RETIREMENT DATE IF APPLICABLE

MonthDayYear
Date
SALARY(GROSS)*
YR
MO
WK
PREV. EMP. IF LESS THAN 3 YEARS:
EMPLOYER
Address

* ADDRESS

Street Address Line 2

* CITY/STATE/ZIPState / Province

Postal / Zip Code
TIME ON PREVIOIUS JOB -YEARS
TIME ON PREVIOUS JOB - MONTHS
PREV. EMP PHONE
** IF EMPLOYMENT LESS THAN 3 YEARS AND ATTENDED SCHOOL PREVIOUSLY:
NAME OF EDUCATIONAL INSTITUTION;
Address

*ADDRESS

Street Address Line 2

* CITY/STATE/ZIPState / Province

Postal / Zip Code
CITY/STATE/ZIP:
PHONE NUMBER
DATES

MonthDayYear
Date
OTHER INCOME
SOURCE
OTHER INCOME
SOURCE
HAVE YOU EVER FILED FOR BANKRUPCY?
YES
NO
HAVE YOU EVER HAD ANY JUDGMENTS?
YES
NO
CERTIFICATION AND SIGNATURES
I CERTIFY THAT THE INFORMATION STATED ABOVE IS COMPLETE AND ACCURATE AND HAS BEEN FURNISHED BY ME KNOWING THAT YOU INTEND TO RELY ON IT IN CONSIDERING MY APPLICATION. I UNDERSTAND THAT YOU MAY REQUEST A CONSUMER CREDIT REPORT IN CONNECTION WITH THIS APPLICATION AND FOR THE PURPOSE OF UPDATING, RENEWING OR EXTENDING FURTHER CREDIT AND IT I ASK, I WILL BE INFORMED WHETHER OR NOT SUCH A REPORT WAS REQUESTED ,AND IF so THE NAME ANDADDRESS OF THE CREDIT REPORTING AGENCY THAT FURNISHED THE REPORT.

I ALSO AUTHORIZE YOU TO CHECK MY EMPLOYMENT HISTORY AND TO EXCHANGE ACCOUNT AND CREDIT INFORMATION ABOUT ME WITH ANYONE WHO MAY ASK OR WITH ANYONE WHO MAY ASK YOU.
Signature of Applicant
Date

MonthDayYear
Date
CUSTOMER CONTACT
Downpayment?*
Vehicle Interested in Year, Make, Model*
Do You have a Trade-in? Year, Make, Model
Trade-in mileage?
Lien holder on Trade-in, if any?
Balance owed on Trade-in?
ADDITIONAL INFORMATION
Should be Empty:

CREDIT APPLICATION

APPLICANT INFORMATION:

** IF EMPLOYMENT LESS THAN 3 YEARS AND ATTENDED SCHOOL PREVIOUSLY:

CITY/STATE/ZIP:

CERTIFICATION AND SIGNATURES