2003 Honda Accord Gold#2598

$5,737.00

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TEL:  770-627-3318

Fax: (770)-627-3350

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CIV STATUS

SINGLEMARRIEDDIVORCEOTHER

ADDRESS

(IF LESS THEN 1 YEAR PROVIDE PREVIUS)

EMPLOYMENT

(IF LESS THEN 2 YEARS PROVIDE PREVIOUS)

TIME ON JOB

TIME ON JOB

SECOND JOB

TIME ON JOB

INCOME

The undersigned herby authorizes selling dealer to initiate a credit investigation based upon the following information, wich information has been voluntarily provided by myself and warrants the truth and accuracy of this information. The undersigned further warrants that a bankruptcy proceeding is neither presently in progress not anticipated and acknowledge receipt of this credit application. The undersigned also understand that if information is found to be fraudullent this application will be subject to termination. The undersigned further recognizes that the Federal Privacy Act, or other laws, rules or regulations may prohibit disclosure of such inforamation without this expressed approval. I herby authorize and investigation of my credit and employment history, to include information obtained from credit reporting agencies.

DATE