Used Cars in Central Valley, NY (845) 928-1000.

30-15 Thomson Ave. Long Island City, NY 11101 | Tel: (718) 472-4444 | Fax: (718) 729-1914 ‎

Personal Information
SSN
First Name*
Middle Name
Last Name*
Suffix
Date of Birth*
Gender*

Current Address
Street #*
Building
Street Direction
Street Name*
Street Type*
Apartment #
City*
State*
Zip*

Contact Information
Home #*
Work #*	x
Cell #
e-mail

Employment Information
Length of stay in area*
Time at Job*
Gross Income $*
Frequency of Income*

Current Residence
Type of Residence
Monthly Payments $
Name of Landlord
Landlord's Phone #

Current Employment
Name of Employer
Address 1
Address 2
City
State
Zip
Type of Work
Additional Income
Source of Additional Income
Frequency of Additional Income

Driver's License Information
Driver's License/Other ID #
State Issued

	Additional Information
Downpayment available $

Driver's License Information
Driver's License/Other ID #
State Issued

	Additional Information
Downpayment available $		Comments

“I represent, warrant and affirm that the above information is true and correct and have been made in order to induce you, the dealer, to grant me credit to acquire a vehicle by relying on the above
knowledge. By submitting this form I authorize you, the dealer, to verify the correctness of the information by verifying my employment and residence and also to acquire other reports, including but
not limited to credit bureau reports, to analyze my credit worthiness. I authorize you to retain this application and any credit agreement as your property.”