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Contact Info

First Name*

Last Name*

Email Address*

Phone #*

Social Security #*

Date of Birth*

Residency Info

Street Address*

Address line 2

City*

State*

Zip Code*

Rent or Own?*

How long have you lived at your current residence*

If less than 2 years please fill out the previous residence information

Monthly Rent/Mortgage*

Previous Residence (If Current Residency is Less Than 2 Years)

Street Address

Address line 2

City

State

Zip

Rent or Own

How long did you lived at this residence

Monthly Rent/Mortgage

Employment info

Employer Name*

Employer Phone #*

Employer Address*

Employer City*

Employer State*

Employer Zip Code*

Employment Type*

Occupation or Job Title*

Gross Monthly Income*

Additional Income

Other Income Source

How long have you worked at employer*

If less than 2 years please add previous employer.

Previous Employment (if with current employer less than 2 years)

Employer Name

Employer Phone

Employer Address

City

State

Zip

Employment Type

Occupation or Job Title

Gross Monthly Income

Additional Income

How Long Were You With This Employer

Co-Applicant Info

First Name*

Last Name*

Email*

Phone #*

Street Address*

Address Line 2

City*

State*

Zip Code*

Rent or Own?*

How long have you lived at this residence?*

Monthly Payment/Rent*

Social Security*

Date of Birth*

Driver's License

Driver's License State

Co-Applicant Employment

Company or Employer Name*

Employer Phone #*

Employer Address*

Employer City*

Employer State*

Employer Zip*

Occupation or Job Title*

Employment Status*

How long have you worked with this employer?*

Gross Monthly Income*

Other Monthly Income Amount

Other Income Source

Tell us about the vehicle you want

Year*

Make*

Model*

Trim*

Total Down*

Trade In

Trade-In Year

Trade-In Make

Trade-In Model

Trade-in Trim

Trade-In Mileage

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I agree to give permission for the above applicant(s) Consumer Credit Report(s) to be obtained, at no cost to me, in order to help determine the types and extent of financing which are available*

In connection with your transaction, Selden Motors may acquire information about you as described in this notice, which we handle as stated in this notice.

We may collect personally identifiable information such as name, postal address, telephone number, e-mail address, social security number, date of birth, etc. This personal information is collected and used by Dealerfire Credit Application staff for the purpose of facilitating a relationship or business transaction.

Our website resides behind a firewall and uses SSL (Secure Sockets Layer, the industry-standard security protocol used to communicate with browsers) to transmit personal information. Data is strongly encrypted during transmission to ensure that personal and payment information is secure. Industry-standard data encryption techniques are used to protect personal information.

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