First Name
Last Name
Middle Initial
Address
City
State		Zip Code
Date of Birth
SS#
Home Phone
E-mail

 

How long have you lived at your current address?
Years		Months
Do You	Rent	Own	Other - Describe Below
Rent or Mortgage Payment		$

Previous Address (If less than 3 years at above)
Address
City
State		Zip Code
How long did you live at this previous address?
Years		Months
Did You	Rent	Own	Other - Describe Below

Current Occupation
Current Employer
Work Phone
Address
City
State		Zip Code
Work Phone
How long have you worked for this employer?
Years		Months
Gross Monthly Income

Previous Employer  (If less than 3 years at above)
Previous Occupation
Previous Employer
Address
City
State		Zip Code
Work Phone
Years		Months
Other Income - Describe Below

Thank you for taking the time to complete this credit application.

In connection with your transaction, Smith Motors, Inc. of Hammond may 
acquire information about you as described in this notice, which we handle as 
stated in this notice.

PRIVACY NOTICE

1. We collect nonpublic personal information about you from the following 
sources:

•Information we receive from you on applications or other forms;
•Information about your transaction with us; and,
•Information we receive from a consumer reporting agency.

2. We do not disclose, nor do we reserve the right to disclose, any nonpublic 
personal information about our consumers, customers or former customers to 
anyone, except as permitted by law. We may disclose non-public information 
information about you, as a consumer, customer or former customer, to 
non-affiliated third parties as permitted by law.

3. We restrict access to nonpublic personal information about you to those 
employees who need to know that information to provide products or services 
to you. We maintain physical, electronic, and procedural safeguards that 
comply with federal regulations to guard your nonpublic personal information.

CUSTOMER ACKNOWLEDGMENT

Please review your answers before submitting.

For the purpose of securing credit, I certify that the above information is true and complete to the  best of my knowledge. I authorize you to check my employment history and obtain information about credit experiences with me, including a credit report from one or more consumer reporting agencies (credit bureaus) in connection with this application.

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