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  • Holy Family School Patoka Cardboard Boat Regatta November 1, 2011
  • Customer Feedack October 31, 2011
  • Customer Feedback October 31, 2011
  • America’s Funniest Home Video and Ruxer Ford Lincoln & Jasper Engines and Transmissions September 7, 2011

Business Credit Application

Thanks for taking the time to fill out a credit application for the Ruxer Truck Center. Be assured that the information you submit is kept secure and confidential.

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Preferred Salesman:	Any Doug Abbett Nick Abbett Jake Bower Tim Eckstein Greg Elsperman David Fromme Garry Hall Harry Hutton Chad Lampert Mike Lampert Darren Matheis Jeff Miller Ron Otto Charlie Stockton Mike Wagner Gary Weinzapfel None
What is the vehicle you are interested in:
Year:
Make:
Model:
Trim (if known):
Primary Applicant: Personal Information
First Name: *
Middle Initial: *
Last Name: *
Address: *
City: *
State: *	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NE NH NJ NM NV NY NC ND OH OK OR PA RI SC SD TN TX UT VI VT VA WA WI WV WY
Zip: *
Time at Residence:*	Years:  Months:
Home Phone: *	E-mail: *
Date of Birth: *	Month:  Day:  Year:
Social Security Number: *
Driver’s License Number: *	State: *  AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NE NH NJ NM NV NY NC ND OH OK OR PA RI SC SD TN TX UT VI VT VA WA WI WV WY
Dwelling Information
Please Check One  of the Following:	Own Home Outright Buying Home Living with Relatives Leasing/Renting Own/Buying Mobile Home
Name of Landlord or  Mortgage Holder:
Address of Landlord or  Mortgage Holder:
Rent or Mortgage  Payment:	$
Education Information
Education Level:	Four Year College Degree or Higher Two Year College Degree Special Training or Trade School Some College High School Graduate
Employer Information
Your Current Employer:
Address:
City:
State:	AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NE NH NJ NM NV NY NC ND OH OK OR PA RI SC SD TN TX UT VI VT VA WA WI WV WY
Zip:
Your Position:
Time on Job:	Years:  Months:
Gross Annual Income:	Before Taxes
Other Income:
Source of Other Income:
Banking Information
Name of Bank:
Please Check  All that Apply:	Checking & Savings Checking Only Savings Only Other None
Do You Have Any Current Auto Loans?	Yes  No
Name of Creditor:
Current Unpaid Balance:	$
Have You Had Any Previous Auto Loans:	Yes  No
Name of Creditor:
Date Opened:
Monthly Payment Amount:	$
Amount Borrowed:	$
Date Closed:
Have You Ever Had a Car or Other Merchandise Repossessed?	Yes  No
If Yes, Date of Repossession:
Have You Ever Had a Bankruptcy?	Yes  No
Has the Bankruptcy been Discharged?	Yes  No
If Yes, Date of Discharge:
Fair Credit Reporting Act Disclosure
By submitting this application, I understand you will be checking with credit reporting agencies and that the information provided by me is complete and accurate to the best of my knowledge. I also understand I may request in writing within a reasonable time a full disclosure report. Though this application will be forwarded to available financial institutions, I understand this does not obligate me in any way to use their financing source(s).
Privacy Notice
In connection with your transaction we may obtain nonpublic personal information about you and that information is handled as stated in this notice. 1. We collect personal nonpublic information about you from the following sources: • Information we receive from you on applications or other forms • Information about your transactions with us, our affiliates or others; and, • Information we receive from a consumer reporting agency. 2. We may disclose all the information we collect, as described above, to companies that perform marketing services or other functions on our behalf or to other financial institutions with whom we have joint marketing agreements. 3. We may also disclose nonpublic personal information about you, as a consumer, customer or former customer, to non-affiliated third parties as permitted by law. 4. Further, we restrict access to your nonpublic personal information to only those employees who need to know that information to provide products or services to you. Employees cannot use your information for any other purpose. For your protection, we maintain physical, electronic and procedural safeguards that comply with federal regulations.
By clicking Submit you agree to the above statement and allow Ruxer Ford Lincoln to check your credit. If you choose not to please click on No Thanks.
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