Secure Credit Application

Keith's Auto Sales West
800 West Market St
Harrisonburg, VA 22801
(540) 434-2817
(877) 434-2817
(540) 574-4203

Keith's Auto Sales
6158 Spotswood Trail
PO Box 111
Penn Laird, VA 22846
(540) 289-9677
Toll Free (877) 292-5798
Fax (540) 289-6006

Ask Your Neighbor!

Email Us

Email us using your online webmail account

GMail

Hotmail

Use desktop email (Outlook, Thunderbird, etc...)
sales@keithsautosales.com

Loan Information

Vehicle you are interested in:
Purpose of loan:
Loan amount requested:
Desired # of monthly payments:
Desired monthly payment:
Amount Down:

Personal Information
Full Name
Marital Status:
Social Security #:	- -
Drivers License # & Expiration	- / /
Date of Birth:	/ /
Email Address:
Home Phone: eg: 234-555-1212
Cell Phone: eg: 234-555-1212
Street 1:
Street 2:
City / State / Zip:
How long have you lived at this address:
Have you lived at the above address for more than 5 years? yes no

Previous Address
Street 1 (if current is less than 2 years):
Street 2:
City / State / Zip:
Date you started living at this address:	/ /
How long did you live at this address:

Financial Information
Rent/Mortgage Monthly Payment
Check all that apply:	checking savings loan credit card other
Have you declared bankruptcy within the last 7 years? yes no
Are you planning to file bankruptcy anytime in the future? yes no

Current Employer
Employer Name:
Job Title:
Phone Number: eg: 234-555-1212
How long have you been working there:
Gross monthly income before taxes:

Previous Employer (if less that 2 years at current job)
Previous Employer (if current is less than 2 years):
Previous Job Title:
Phone Number: eg: 234-555-1212
How long did you work there:

Additional Income
Additional Monthly Income:
Additional Monthly Income:
NOTE: 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.

Spouse's Personal Information
Spouse's Full Name
Spouse's Social Security #:	- -
Spouse's Drivers License & Exp Date	- / /
Spouse's Date of Birth:	/ /
Spouse's Email Address:
Spouse's Home Phone: eg: 234-555-1212
Spouse's Cell Phone: eg: 234-555-1212
Street 1:
Street 2:
City / State / Zip:
How long has your spouse lived at this address:
Has your spouse lived at the above address for more than 5 years? yes no

Spouse's Previous Address
Street 1 (if current is less than 2 years):
Street 2:
City / State / Zip:
How long did your spouse live at this address:

Spouse's Financial Information
Check all that apply:	checking savings loan credit card other
Has your spouse declared bankruptcy within the last 7 years? yes no
Is your spouse planning to file bankruptcy anytime in the future? yes no

Spouse's Current Employer
Spouse's Employer Name:
Spouse's Job Title:
Phone Number: eg: 234-555-1212
How long has your spouse been working there:
Gross monthly income before taxes:

Spouse's Previous Employer (if less that 2 years at current job)
Spouse's Previous Employer (if current is less than 2 years):
Spouse's Previous Job Title:
Phone Number: eg: 234-555-1212
Date your spouse began working there:	/ /

Spouse's Additional Income
Spouse's Additional Monthly Income:
Spouse's Additional Monthly Income:
NOTE: 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.