APPLICANT INFORMATION

First Name:

Last Name:
Address:
City: State:
Zip:
Home Phone:
Length at Residence:
Date of Birth:
Social Security No.:



  EMPLOYMENT INFORMATION

Employer:

Employer's Phone:
Income: $
Length at Job:



Is this an individual or joint application?
Individual Joint

  DESIRED VEHICLE

Make:

      Model:
Year:

       Color:

  RELEASE STATEMENT

Yes, I have read and understand how the information I have provided above will be used and handled by Bermans Automotive.

The above information is given for the purpose of obtaining credit. I (we) hereby certify that the statements contained herein are true and correct, and authorize, by submitting this form, that G&M Automotive check my (our) credit and employment information.



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