General   I

 First Name: 

 Last Name: 

 Email Address: 

 Social Security No:

Example: 111-22-3333

 Birth Date:

Example:  03/04/1978

 Address:

 City: 

 State:

 Zip Code: 

 Telephone Number: 

Example: 111-222-3333

 Time at Residence:

Years 0 years 1 years 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 11 years 12+ years      Months 0 months 1 months 2 months 3 months 4 months 5 months 6 months 7 months 8 months 9 months 10 months 11 months 12+ months

 Residence Type:

Rent Own

 Rent/Mortgage:

$

Financial

 Banking Type:

Checking Savings Both

 Financing Preferred:

Purchase Lease

 Loan Term (Months):

 Amount Required:

$

 Time of Purchase:

 Down Payment:

$

 Trading in Vehicle?

No Yes

 Year:

 Make:

 Model:

 Mileage:

 Estimated Pay Off:

$

Employment

 Employer: 

 Gross Monthly Income: 

$

 Occupation: 

 City/State/Zip: 

 Work Telephone: 

Example: 336-111-2222

 Time on the Job:

Years 0 years 1 years 2 years 3 years 4 years 5 years 6 years 7 years 8 years 9 years 10 years 11 years 12+ years     Months 0 months 1 months 2 months 3 months 4 months 5 months 6 months 7 months 8 months 9 months 10 months 11 months 12+ months

 Other Income:

 Gross Amount:

$

.

Acknowledgement and Consent To the best of my knowledge, I certify that the information above is accurate and complete. This application may be retained by creditors whether or not it is approved. Creditors may use this information to determine whether or not to provide the requested credit. I understand that I could be subject to criminal penalties for providing false information. 
.

Your Salesperson's Name: (If Applicable)
I I have read, I understand and I agree to the Nichols Privacy Policy. Required. Go to Privacy Policy.