NAME:_____________________________PHONE____________________________

ADDRESS_________________________________________________________                    WORK PHONE _________________________

CITY _________________________STATE _____________ZIP__________________

SOCIAL SECURITY # ___________________DATE OF BIRTH __________________

HOW LONG AT ADDRESS: ____________________________

PREVIOUS ADDRESS IF LESS THAN 3 YEARS

______________________________________________________ HOW LONG______

BUYING OR RENTING ________________________

MONTHLY PAYMENT$_____________________ MADE TO __________________

EMPLOYMENT:

BUSINESS NAME ________________________________ HOW LONG___________

SUPERVISOR ____________________________________POSITION _____________

ADDRESS _______________________________________

                   _______________________________________

EARNINGS:  MONTH $ ________________

PREVIOUS EMPLOYER IF LESS THAN 3 YEARS

BUSINESS NAME _________________________________ HOW LONG __________

SUPERVISOR   ____________________________________ POSITION ___________

THE UNDERSIGNED HEREBY AUTHORIZED SELLING DEALER OR FINANCE COMPANY TO INITATE A CREDIT INVESTIGATION BASED UPON THE ABOVE INFORMATION, WHICH INFORMATION HAS BEEN VOLUNTARILY PROVIDED BY MYSELF, AND WARRANTS THE TRUTH AND ACCURACY OF THIS INFORMATION. THE UNDERSIGNED FURTHER WARRANTS THAT A BANKRUPTCY PROCEEDING IS NEITHER PRESENTLY IN PROGRESS NOR ANTICIPATED.

SIGNATURE OF APPLICANT _______________________________________________________

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