Madison Motors

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Secure Credit Application

Your application will be submitted via our secure server connection.

Fields in blue are required

Credit Information

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 & Exp Date	- / /
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:

Previous Address
Street 1:
Street 2:
City / State / Zip:
How long did you live at this address:

Financial Information

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:
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:

Spouse's Previous Address
Street 1:
Street 2:
City / State / Zip:
How long did your spouse live at this address:

Spouse's Financial Information

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:
Spouse's Previous Job Title:
Phone Number: eg: 234-555-1212
How long did your spouse work there 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.

Financial Debts / Obligations
Type of Debt	Holder	Balance	Monthly Payment

Personal References
Relationship	Name	Address	Phone

Check this box to authorize us to share your nonpublic personal information with affiliated and/or nonaffiliated third parties. I understand that in checking this that you may be better able to serve me and that I may receive offers for other products and services that may be of value to me. Please read our privacy policy for more information regarding your rights and how we use the personal information you submit to us.

Please type your full name here:
(This will act as your digital signature. Your application cannot be accepted unless this is signed.)

FAIR CREDIT REPORTING ACT DISCLOSURE:

This application for credit may be submitted by the Dealer to various financial institutions. Before this application is submitted, the Dealer will disclose to you the name and address of the institution(s) who will receive copies of this application.

By clicking on the 'submit' button below I certify that the above entered information to be true and correct and I hereby authorize you to use this information to perform a credit rating check of my personal credit. I also certify that I am over the age of 18 and am a current U.S. citizen or permanent resident. In addition, I understand that submitting the above information does not represent an obligation by any party to provide credit nor does it obligate me to accept any credit offered.

Madison Motors
	2736 South Seminole Trail (Route 29 South) Madison, VA 22727 (540) 948-3122 tel (540) 948-5453 fax sales@madisonmotors.com Map & Directions
Family Owned & Operated for Over 30 Years!