ON THE ROAD APP
Pre-Qualification Form
Desire Funding Amount?
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First Name
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Middle Name
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Last Name
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Birth Date
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Please select a month
January
February
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June
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Month
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Day
Please select a year
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Year
SSN
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Email Address
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Best Contact Number
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-
Area Code
Phone Number
Current Residence Address
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APT_Number
City
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State
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Zip_Code
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Ownership
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Rent
Own
# Of Years At This Residence
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More Than 2 Years
Less Than Two Years
Business Name
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TAX ID
Business DBA
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LLC
DBA
INC
Other
No Business yet
Please choose
Company Start Date
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Month
-
Day
Year
Date
Industry Experience
*
Years
Monthly Gross Income
*
$
Company Industry
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Whats your Credit Score?
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Bankruptcy in the past?
YES
NO
Have you had any Car Repos?
YES
NO
Are you behind on Child-Support more then $1000 Dollars?
YES
NO
Client Approval: By completing my name below and submitting this form, I authorize La Joya Capital Group, LLC . to order a copy of my full credit report to use in conjunction with this pre-qualification worksheet. Please type in your full name.
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