8750 N. County Road 25
Piqua, Ohio 45356
(937) 606-2400
810 W. Russell Rd.
Sidney, Ohio 45365
937-498-9000
1099 N. County Road 25A
Troy, Ohio 45373
937-339-6000
1315 Sweitzer St.
Greenville, Ohio 45331
937-459-5050
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Applicant Information
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Middle Name:
Last Name:
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Social Security:
Date of Birth:
April, 2018
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12
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MS
MO
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OR
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1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years
10 Years
11 Years
12+ Years
Months:
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1 Month
2 Months
3 Months
4 Months
5 Months
6 Months
7 Months
8 Months
9 Months
10 Months
11 Months
Residence Type:
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Landlord Name:
Landlord Phone:
Living Arrangements:
Own
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Applicant Previous Residence
Complete if you've been at your current Residence for less than 2 years.
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Time at Residence:
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1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years
10 Years
11 Years
12+ Years
Months:
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1 Month
2 Months
3 Months
4 Months
5 Months
6 Months
7 Months
8 Months
9 Months
10 Months
11 Months
Residence Type:
Rent
Own
Landlord Name:
Landlord Phone:
Living Arrangements:
Own
Rent
Live with Parents
Live with Others
Applicant Employment Information
Employer:
Occupation:
Address 1:
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7 Years
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10 Years
11 Years
12+ Years
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1 Month
2 Months
3 Months
4 Months
5 Months
6 Months
7 Months
8 Months
9 Months
10 Months
11 Months
Applicant Previous Employer
Complete if you've been at your current Employment for less than 2 years.
Employer:
Occupation:
Address 1:
Address 2:
City/State/Zip:
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DE
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HI
ID
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KY
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ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Work Phone:
Time on Job:
Years:
0 Years
1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years
10 Years
11 Years
12+ Years
Months:
0 Months
1 Month
2 Months
3 Months
4 Months
5 Months
6 Months
7 Months
8 Months
9 Months
10 Months
11 Months
Income Information
Hourly Rate or Salary Amount:
Average Hours Worked Per Week:
Pay Frequency:
Weekly
Bi-Weekly
Monthly
Semi-Monthly
SSI Amount:
Any Additional Monthly Income:
Monthly Expenses
Rent/Mortage:
Electric/Gas:
Cell Phone/Phone:
Cable/Sat/Internet:
Credit Card Payment:
Other Car Payments:
Other Monthly Payments:
Trade-In Information
Trade Year:
Trade Make:
Trade Model:
Trade Trim:
Trade Color:
Trade Mileage:
Trade VIN:
Trade Payoff:
Trade Payoff Good Thru:
April, 2018
Sun
Mon
Tue
Wed
Thu
Fri
Sat
14
1
2
3
4
5
6
7
15
8
9
10
11
12
13
14
16
15
16
17
18
19
20
21
17
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25
26
27
28
18
29
30
1
2
3
4
5
19
6
7
8
9
10
11
12
Today
Clear
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
OK
Cancel
Trade Lien Holder Address 1:
Trade Lien Holder Address 2:
Trade Lien Holder City/State/Zip:
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Additional Comments
ACKNOWLEDGMENT AND CONSENT:
I certify that the above information is complete and accurate to the best of my knowledge. Creditors receiving this application will retain the application whether or not it is approved. Creditors may rely on this application in deciding whether to grant the requested credit. False statements may subject me to criminal penalties. I authorize the creditors to obtain credit reports about me on an ongoing basis during this credit transaction and to check my credit and employment history on an ongoing basis during the term of the credit transaction. If this application is approved, I authorize the creditor to give credit information about me to its affiliates.
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