Secure Finance Application

Statement of Consent

I certify that the information provided is accurate and current. I also understand that I am authorizing Bert's Mega Mall to contact me regarding the contents of this application, with the intention of checking my bureau through an established credit reporting agency. I authorize an examination of my credit and employment history, and the release of information about my credit experience.

Please initial below to indicate that you have received a copy of our Privacy Notice and agree to the above statements.

YOUR CREDIT APPLICATION IS GOING THROUGH A SECURE WEBSITE.

Initial Here

Co-Applicant's Initial Here

Vehicle Information

Type

Condition

Year

Make

Model

Down Payment

Your Contact Information

Name As It Appears on Driver's License

First Name

Middle Name

Last Name

Driver's License

Work Phone

Residence Phone

E-mail

Date of Birth

Physical Address Information

Physical Address

City

State

Zip

County

Housing Information

Do you Rent or Own your home, or other?

Rent / Mortgage Monthly Amount

Time at Residence

Employer Information

Occupation

Employer Name

Employer Address

Employer City

Employer State

Employer Zip

Employer Phone

Salary (Monthly Gross)

Time at Employer

Previous Employer Information (If less than 5 years at Current Employer...)

Occupation

Employer Name

Employer Address

Employer City

Employer State

Employer Zip

Employer Phone

Salary (Monthly Gross)

Time at Employer

Additional Comments

Please include any information that you feel may help us process your application.

Joint Applicant Contact Information

First Name

Middle Name

Last Name

Driver's License

Work Phone

Residence Phone

E-mail

Date of Birth

Joint Physical Address Information

Physical Address

City

State

Zip

County

Joint Applicant Housing Information

Do you Rent or Own your home, or other?

Rent / Mortgage Monthly Amount

Joint Applicant Employer Information

Occupation

Employer Name

Employer Address

Employer City

Employer State

Employer Zip

Employer Phone

Salary (Monthly Gross)

Time at Employer

Joint Previous Employer Information (If less than 5 years at Current Employer...)

Occupation

Employer Name

Employer Address

Employer City

Employer State

Employer Zip

Employer Phone

Salary (Monthly Gross)

Time at Employer

Joint Applicant Additional Comments

Please include any information that you feel may help us process your application.

References

Name

Phone

City

State

Name

Phone

City

State

Disclaimer

Please initial below to indicate that you have received a copy of our Privacy Notice and agree to the above statements.

YOUR CREDIT APPLICATION IS GOING THROUGH A SECURE WEBSITE.

Initial Here

Co-Applicant's Initial Here

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