COUNTRY AUTO SALES AND SERVICE INC.

1230 STAFFORD ROAD TIVERTON RI

PHONE: 1(401)624-6913 FAX: 1(401)624-2980

CREDIT APPLICATION

Individual [ ] Joint [ ] If this is a joint application, we intend to apply for joint credit.

Applicant (Initials) APPLICANT A US CITIZEN? YES [ ] NO [ ]

APPLICANT (LAST, FIRST) / BUSINESS NAME: / DEALER TO COMPLETEHIGHLIGHTED SECTION
SOCIAL SEC: LIC# AND STATE: / DATE OF BIRTH: / VIN NUMBER
HOME PHONE: CELLPHONE: / EMAIL: / VECHILE DETAILS:
[ ] NEW [ ] USED
STREET ADDRESS: / YEAR/MAKE/MODEL
CITY/STATE/ZIP: / TIME THERE: YRS MOS / MILAGE: BODY STYLE:
MAILING ADDRESS: / DETAILS:
PREVIOUS ADDRESS: / TIME THERE:
______YRS______MOS / [ ] 4X4
[ ] BEDLINER
[ ] BOSE RADIO
[ ] PW SEATS
[ ] PW SUNROOF
[ ] LEATHER SEATS
[ ] RUNNING BOARDS / [ ] ALLOY WHEEL
[ ] C.D
[ ] CAPT. CHAIR
[ ] PW LOCKS
[ ] CRUISE/TILT
[ ] LUGGAGE RACK
[ ] SNOW PLOW PKG.
MORTGAGE/RENT PAYMENT:
$
[ ]OWN [ ]RENT [ ] OTHER / MORTGAGE HOLDER/LANDLORD: / [ ] THEFT RECOVER
[ ] CAMPER PKG.
[ ] ALARM / [ ] TOWING PKG.
[ ] W/OUT AUTO
[ ] OTHER
EMPLOYED BY: / POSITION: / TRADE IN: YEAR: / MAKE:
EMPLOYER ADDRESS (CITY, STATE): / GROSS EMPLOYMENT INCOME: $
[ ] MONTHLY [ ] ANNUAL / TIME THERE:
______YRS
______MOS
BUSINESSS PHONE (AREACODE+NUMBER) WORK EXT. / OTHER INCOME*:
SOURCE: / AMOUNT:
S
PREVIIOUS EMPLOYER/POSTION
/ TIME THERE: ______YRS ______MOS
CURRENT BANK: TYPE OF ACCOUNTS:
-OTHER INCOME NOTE: ALIMONY, CHILD SUPPORT OR SEPARATE MAINTENANCE INCOME NEED NOT BE REVEALED IF YOU DO NOT CHOOSE TO HAVE IT CONSIDERED AS A BASIS FOR REPAYING THIS OBLIGATION.
FAIR CREDIT REPORT ACT NOTICE TO CONSUMER
This will advise you that your retail installment sales contract and buyer's application for secured credit will be submitted to financial sources other than Country Auto Sales Inc. for consideration as to whether you meet their credit requirement for purchase. I/we agree to inquire about the status of this application by contacting Country Auto Sales Inc. within 5 days from dated sales purchase, I/we understand that this application may be considered or withdrawn due to credit information. I/we authorize Country Auto Sales Inc. and their selected financialsources to review this application, investigate my/our credit and employment history, obtain consumer reports on me/us and answer questions about credit experience with me/us.
APPLICANT’S SIGNITURE DATE:
X______