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Individual Applicant |
Joint Applicant for
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APPLICATION
Toll Free: (800) 656-6858
FAX No: (870) 535-0660 |
| Email
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| CUSTOMER CONTACT INFORMATION
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Best Time to Call Primary
Phone
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| Cell Phone #
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Home Phone #
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Other Phone # (Relative, Friend,
etc.)
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| CUSTOMER INFORMATION
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Last Name
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First Name
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| Social Security #
(xxx-xx-xxxx) |
Date of Birth
(MMDDYYYY) |
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| RESIDENCE INFORMATION
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How long at address? Yrs
Mos
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Address No
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| Street Name
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Apt #
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City
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| State
Zip Code
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Person who's name appears
on residence utilities
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| MAILING INFORMATION
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Address No
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Street Name
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| Apt #
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City
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State
Zip Code
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| Own/Rent?
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Monthly Pmt
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| Landlord Name
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Landlord Address
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| PRIMARY EMPLOYMENT
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Employer Name
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Dept or Military Rank (if applicable)
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| Occupation
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Address No
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Street Name
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| Phone #
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City
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State
Zip Code
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| Supervisor |
Monthly Income (Gross)
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Pay Frequency
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| Work Schedule
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Hire Date
(MM/YYYY) |
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| SECONDARY EMPLOYMENT
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Employer Name
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Hire Date
(MM/DD/YYYY) |
| Address No
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Street Name
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Phone #
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| City
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State
Zip Code |
Supervisor
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| Monthly Income (Gross)
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Pay Frequency
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| OTHER INCOME
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**Other Income Source
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**Amount and Frequency of Other
Income
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| **Alimony, child
support or separate maintenance income need not be revealed if you
do not wish to have it considered as a basis for repaying this
obligation. |
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| BANK INFO
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Savings Account
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Checking Account
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| Direct Deposit
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| Vehicles of Interest: |
Second Choice:
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| California Applicant: |
If you are married, you
may apply for a separate account. |
| Ohio Applicants: |
The Ohio laws against
discrimination require that all creditors make credit equally
available to all credit worthy customers, and that credit reporting
agencies maintain separate credit histories on each individual upon
request. The Ohio Civil Rights Commission administers compliance
with this law. |
| Maine Applicants: |
You are required by the
terms of the contract. You have the right to free choice in the
selection of the agent and insurer through or by which the insurance
is to be placed, including the right to choose an agent or broker
whether or not that agent or broker is affiliated with the creditor.
Obtaining insurance products from a particular agent or broker does
not affect credit decisions by the creditor. Obtaining insurance
products from a particular agent or broker does not affect credit
decisions by the creditor regarding you, unless the insurance
product violates the terms of the extension of credit regarding the
adequacy of coverage or is otherwise not approved by the creditor. |
| New York Applicants: |
In connection with your
application for the credit, a consumer report (credit report) may be
requested. On your request, we will advise you if the report was
actually ordered, and if so, the name and address of the agency that
furnished the report. |
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WISCONSIN RESIDENTS
ONLY: Notice to Married Applicants: No provision of any marital
property agreement, a unilateral statement under Wis. Stat. § 766.59
or a court decree under Wis. Stat. § 766.70 adversely affects the
interest of the creditor unless the creditor, prior to the time the
credit is granted, is furnished a copy of the agreement, statement
or decree or has actual knowledge of the adverse provision when the
obligation to the creditor is incurred.
The credit being applied for, if granted, will be incurred in the
interest of my marriage or family. I understand that the creditor
may be required by law to give notice of the credit transaction to
my spouse. |
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I acknowledge that
pursuant to the Fair Credit Reporting Act, my application
will be submitted to Credit Acceptance Corporation, a Michigan
corporation, and/or any of its affiliates or subsidiaries or
divisions ("Credit Acceptance") for review in connection with the
assignment of a sales finance contract written, or to be written, in
connection with my purchase.
I certify that the above information is complete and accurate. In
connection with this application, I authorize and give Seller and
Credit Acceptance my consent to obtain my credit report from any
Credit Reporting Agency and complete an investigation of my credit
and employment history and release information about my credit
experience with Seller and/or Credit Acceptance. If and after my
contract is assigned to Credit Acceptance, I also authorize and give
consent to Credit Acceptance to obtain my credit report from any
Credit Reporting Agency at any time during the term of my contract
for any purpose whatsoever, including but not limited to for
prescreening, as defined and permitted from time to time by the
Federal Trade Commission; for reviewing my contract; to defer or
extend my payments or due date under my contract; to take collection
action on my contract; or for other legitimate purposes associated
with my contract. I understand and acknowledge that Credit
Acceptance will retain this application whether or not it is
approved. I also understand and acknowledge that if I ask, I will be
informed if a credit report has been requested in connection with
this application for credit, and the name and address of the Credit
Reporting Agency that furnished the report.
*Email Communication: By signing below I authorize and give consent
to Credit Acceptance to use the email address I have provided on
this application to communicate with me for any purpose whatsoever,
including but not limited to communications regarding my account
activity, status and collections.
Spousal Consent: By signing below I authorize and give consent to
Credit Acceptance to discuss my account with my spouse, if
applicable, including discussing my account activity, status and
payment arrangements |