Credit Request

About You

First Name: Middle Initial: Last Name:

You birth date:

Social Security #:

Email Address :

How did you hear about us:

Address

Address:

City:

State:

Zip:

Phone

Daytime: Cell:

Residence

Years: Months: Rent or Mortgage: $

Income and Employment

Employment: Employer Name:

Employer Phone:

Monthly Income:

Other Income Other Income Source:

Credit Status

Are you in the process of filing for bankruptcy?
Have you had a charge-off or repossession in the last three years?

Have you read and do you understand the privacy notice and give us permission to pull your credit? (read below)

To comply with federal law, McCurry Motor Co. Inc. and its affiliate Auto Finance Group, ("we") must provide consumers with the following information about how nonpublic information is collected and disclosed: We collect non public information about you from the following sources: Information we receive from you on applications or other forms; Information about your transactions with us, or affiliates, or others; and Information we receive from a consumer reporting agency. We do not disclose any nonpublic personal information about our customers or former customers to anyone, except as permitted by law. We may disclose all of the information we collect, as described above, to companies that perform marketing services on our behalf or to other financial institutions with whom we have joint marketing agreements. 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.

Note: You have two options for submitting an application:

1. Fill out the form and submit it online, or

2. Visit the lot nearest you and fill one out.