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Applicant Information
First Name:
Middle Name:
Last Name:
Address 1:
Address 2:
City/State/Zip:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
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NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
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VA
WA
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WI
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Social Security:
Date of Birth:
February, 2019
Sun
Mon
Tue
Wed
Thu
Fri
Sat
05
27
28
29
30
31
1
2
06
3
4
5
6
7
8
9
07
10
11
12
13
14
15
16
08
17
18
19
20
21
22
23
09
24
25
26
27
28
1
2
10
3
4
5
6
7
8
9
Today
Clear
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
OK
Cancel
Drivers License Number:
Drivers License State:
AL
AK
AZ
AR
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Drivers License Exp:
February, 2019
Sun
Mon
Tue
Wed
Thu
Fri
Sat
05
27
28
29
30
31
1
2
06
3
4
5
6
7
8
9
07
10
11
12
13
14
15
16
08
17
18
19
20
21
22
23
09
24
25
26
27
28
1
2
10
3
4
5
6
7
8
9
Today
Clear
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
OK
Cancel
Mobile Phone:
Home Phone:
Email:
Time at Residence:
Years:
0 Years
1 Year
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 Month
2 Months
3 Months
4 Months
5 Months
6 Months
7 Months
8 Months
9 Months
10 Months
11 Months
Residence Type:
Rent
Own
Living with Family
Military Housing
Other
Rent/Mortgage:
Applicant Employment Information
Employer:
Monthly Income:
Occupation:
Address 1:
Address 2:
City/State/Zip:
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CT
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DE
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HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Work Phone:
Time on Job:
Years:
0 Years
1 Year
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 Month
2 Months
3 Months
4 Months
5 Months
6 Months
7 Months
8 Months
9 Months
10 Months
11 Months
Vehicle Information
Stock Number:
Year:
Make:
Model:
Trim:
VIN:
Mileage:
Sales Price:
Additional Comments
ACKNOWLEDGMENT AND CONSENT:
I certify that the above information is complete and accurate to the best of my knowledge. Creditors receiving this application will retain the application whether or not it is approved. Creditors may rely on this application in deciding whether to grant the requested credit. False statements may subject me to criminal penalties. I authorize the creditors to obtain credit reports about me on an ongoing basis during this credit transaction and to check my credit and employment history on an ongoing basis during the term of the credit transaction. If this application is approved, I authorize the creditor to give credit information about me to its affiliates.
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Affordable Auto Rental & Sales 1
,
310 Dixieway North
,
South Bend
,
IN
46637
574-277-8221
https://www.affordablerental.net