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» Contact Information
First Name: Middle Initial: Last Name:
Street Address: Apt/Suite #:
City: State: Zip Code:
Home Phone #: Alt. Phone #:
Email Address:  
» Credit Information
Social Security #: - - Date of Birth: / /
Housing Type: Mortgage or Rent Payment: $
Length of Time at Current Address:  
Previous Address (Only required if at current address less than 2 years)
Street Address: Apt/Suite #:
City: State: Zip Code:
Length of Time at Previous Address:  
Have you filed for bankruptcy in the past 12 months? YES NO
If yes, has your bankruptcy been discharged? YES NO
Have you had a vehicle repossession in the past 12 months? YES NO
» Employment History
Current Employer Information
Employer: Occupation:
Gross Monthly Income: $ Length of Employment:
Street Address: Unit/Suite #:
City: State: Zip Code:
Previous Employer Information (Only required if current employment less than 2 years)
Previous Employer: Occupation:
Gross Monthly Income: $ Length of Employment:
Street Address: Unit/Suite #:
City: State: Zip Code:
» Trade-In Vehicle Information
Vehicle Year: Make: Model:
Mileage: Lien Holder:
Current Payment: $ Payoff Amount: $
» Desired Vehicle Information
Vehicle Year: Make: Model:
Color: Additional Features:
Desired Payment Amount: $  
» Contact / Appointment Information
What is the best time to call regarding your application?  
Would you like to set up an appointment? YES NO
Select a convenient day for an appointment:  
Select a convenient time during the day:  
» Additional Information
Where did you hear about us?
Additional Comments:
»
By clicking the Submit button above, you certify that all of the statements in this application are true and complete and are made for the purpose of obtaining credit. You authorize Potratz Partners Automotive Advertising and NyEZCredit.com to share your application and related information with its lending partners in order to complete the processing of this application. You authorize Potratz Partners Automotive Advertising and NyEZCredit.com and its lending, marketing, and affiliate partners to retain and rely on your application and to access your credit report in order to evaluate your credit application. In addition, you acknowledge that you have read the state specific notices related to your application, agree to receive Electronic Documents, and have reviewed the privacy policy. By clicking the Submit button below, you further authorize Potratz Partners Automotive Advertising and NyEZCredit.com third party lending institutions, dealers, affiliate or marketing partner to share information in your application, and any other credit information they obtain, with other third parties who may be able to offer or arrange for a direct loan and or dealer financing or other products and services. Copyright © 2006, All Rights Reserved.
 
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