Merchant Application-Sylacauga

Citizens Finance of Sylacauga, Inc.

Telephone: (256) 245-6602
Merchant Name? *
Merchant Location? *
Tell Us What You Need
What kind of loan do you need today? *
Requested Loan Amount *
Down Payment Amount (if any)
Special Financing Requested
Applicant's Personal Information
First Name *
Middle Initial
Last Name *
Date of Birth *
SSN *
Marital Status *
Home or Cell Phone *
Work Phone *
Email Address *
Are you a member of the military or a dependent of someone who is a member of the military? *

Yes No
Applicant's Current and Previous Address
Housing Status *
Monthly Rent/Mortgage Payment *
Address *
Address Line 2
City *
State *
Zip *
Length of Time at Current Address (years & months):
Years *
Months *
Previous Address
Previous Address Line 2
Previous City
Previous State
Previous Zip
Applicant's Employment History
Current Employer *
Length of Employment
Length of time at your current employer (years & months):
Years *
Months *
Current Position *
Work Phone
ext.
How often are you paid? *
Average Take Home Pay *
Previous Employer (If Current is Less Than 2 Years)
Previous Length Of Employment
Application Type
Is this an "Individual" or "Joint" Application?

Individual Joint
NOTE: If you would like to apply for a Joint Loan, each person should complete a separate application.
Additional Income
NOTE: 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.
Current Creditors
Items Purchasing (if applicable)
Type a question
Auto Information (if purchasing auto)
Make
Model
Year
Mileage (numbers only)
Comments
References
#1 Reference Name *
#1 Reference Telephone Number *
#2 Reference Name *
#2 Reference Telephone Number *
Please tell us who submitted this application.
Please select one. *

The application data was provided by applicant to dealer and submitted at the request of applicant. The application was submitted by the applicant.
If any required information is not provided, this application will be considered incomplete.
PLEASE READ BEFORE PROCEEDING
FCRA Disclosure Regarding Account Information

From time to time, Citizens Finance of Sylacauga, Inc. ("Creditor") may share information about me with its affiliates. I may prohibit your doing so except for information pertaining solely to transactions or experiences between Creditor and me by providing written notice to Creditor. Such notice will include my account/loan number, name of account holder, address, and telephone number; and will be sent to:

FCRA Compliance Department
1369 W. Fort Williams Street
Sylacauga, Alabama 35150

Further, if I believe that any information relating to me held by Creditor is inaccurate, I will notify Creditor of the specific information that is inaccurate at the above address.

Consent and Authorization:

The information that I have stated in this Application is complete and correct, and no material debts have been omitted. I acknowledge that Creditor is relying upon the complete accuracy of the information submitted, and that false or misleading information constitutes an attempt to defraud Creditor. I hereby authorize Creditor to obtain, verify and confirm any information about me, or my credit and employment history, or such other information as Creditor may require concerning the statements made in this Application, from credit reporting agencies, directly from my creditors, my landlord or other business or individuals, and my current or former employers.

I hereby authorize and consent to any third party’s releasing such information to Creditor. This authorization includes but is not limited to Creditor’s contacting non affiliated finance companies

that may be listed on the Application or credit report for the purposes of inquiring about previous extensions of or applications for credit.

I additionally authorize Creditor to answer questions from my present or potential creditors about Creditor’s experience with me, or from others whom I may have authorized to receive such information.
Do you agree to these terms? *

I agree
Name of Applicant *

First Name Last Name
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Citizens Finance of Sylacauga, Inc.

Tell Us What You Need

Applicant's Personal Information

Applicant's Current and Previous Address

Applicant's Employment History

Application Type

Additional Income

Current Creditors

Items Purchasing (if applicable)

Auto Information (if purchasing auto)

References

Please tell us who submitted this application.

If any required information is not provided, this application will be considered incomplete.

PLEASE READ BEFORE PROCEEDING