Bob Crock
Internet Sales Manager
3101 7th Street
Parkersburg, WV 26101
Sales/Service/Parts/Body Shop: 304 424-5122
Service Scheduling: 833.229.1001
Internet Sales: 304.966.2068
[email protected]
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LastName
EmailAddress
Email
First Name:
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Middle Initial:
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Last Name:
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Who is your salesperson? If none, then enter N.A.
Date of Birth (mm/dd/yyyy):
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SSN#:
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Address:
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City:
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State:
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Phone:
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Email:
Residence:
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Own home outright
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Living with relatives
Monthly Payment:
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Time at residence:
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Education Level (if under 27)
4 Year College Grad.
2 Year College Grad.
Some College
Special Training
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Current Employer:
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Employer's Address:
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Applicant's Occupation:
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Time at Current Job:
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Work Phone:
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Gross Salary:
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Other income:
Type of Other Income
Social Security
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Alimony or Palimony
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Name of Bank:
Type of Account:
Checking and Savings
Checking only
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Have you ever had a car or other merchandise repossessed?
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Yes
No
Have you ever filed bankruptcy?
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Yes
No
Do you have a co-applicant?
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Co-Applicant First Name:
Co-Applicant Middle Initial
Co-Applicant Last Name:
Co-Applicant Date of Birth: (mm/dd/yyyy)
Co-Applicant SSN#
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MO
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NM
NY
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OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Co-Applicant Phone:
Co-Applicant Email:
Co-Applicant Residence
Own home outright
Buying Home
Renting/Leasing
Living with relatives
Co-Applicant Montly Payment:
Co-Applicant Time at residence:
Co-Applicant Current Employer:
Co-Applicant Occupation:
Co-Applicant Employer Address:
Co-Applicant Time at Current Job:
Co-Applicant Work Phone:
Co-Applicant Gross Salary:
I (and Co-Applicant) have read the Privacy Statement and fully understand its terms.
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BY SUBMITTING THIS CREDIT APPLICATION I (AND CO-APPLICANT) AUTHORIZE A CREDIT CHECK WHICH INCLUDES PULLING STATEMENTS FROM THE CREDIT BUREAU AND OTHER CREDIT REPORTING AGENCIES
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