DX1 Listings finance department located in Oregon City, OR.

Quick Secure Finance Application

Model of Interest

Personal Information

First Name*

Last Name*

Date of Birth*

Social Security Number*

Driver's License Number*

Driver's License State*

Email Address

Home Phone*

Address Information

Street Address*

City*

State*

Zip Code*

Years at Current Address

Credit Information

Do You Have an Auto Loan?*Yes
No

Auto Loan Institution

Monthly Payment

Have You Ever Been Subject to Bankruptcy Proceedings?*Yes
No

If Yes, Please Explain:

Have You Ever Obtained Credit Under a Different Name?*Yes
No

If Yes, What Name?

Have You Ever Had a Vehicle Repossessed?*Yes
No

If Yes, Please Explain:

Entering your name below constitutes your signature, and confirms that: 1) You are submitting this Application for the purpose of applying for a loan and affirms that the information furnished in this Application is true, complete, and correct. 2) You authorize us to request consumer reports from consumer-reporting agencies and information from credit references and other sources disclosed by you in considering this Application and subsequently in order to update, review, renew, extend, or collect the credit we approve. Upon your request, we will inform you of the name and address of each consumer-reporting agency from which we obtained a consumer report on you. 3) Married applicants may apply for an individual loan. 4) You represent that this loan will be used only for personal, family or household purposes. Typing your name below constitutes your signature and authorizes the processing of your Application.

Signature*

Signature Date*

Add Joint Applicant?

First Name*

Last Name*

Birth Date*

Social Security Number*

Driver's License Number*

Driver's License State*

Address Information

Street Address*

Zip Code*

Years at Current Address

Relationship to Applicant*

Home Phone*

Signature*

Date*

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Store Information
Address:	2810 19th Place South Homewood, AL 35209
Phone:	205.871.8186
Fax:	888.111.2222