Special Needs Vehicles
Consumer Credit Application: 3- to 5-year

This form requires a signature. Please fill out the form, press the submit button. Pressing the submit button will print out your records and send a copy of the information to us. After printing out the application, please fax it or mail it to us -- we cannot act on it until we receive the application form by fax or mail. This credit application form is for those with an excellent credit rating.
PLEASE read these directions
BEFORE completing this application.
  • If applying for individual credit in your own name and relying only on your own income or assets for repayment of the credit requested, complete Section B.
  • If applying for joint credit with another person, complete Sections B and C.
  • If applying for individual credit, but are relying on income from alimony, child support, separate maintenance or on the income or assets of another person as the basis for repayment of the child requested, complete Section B and provide information in Section C about the other person.
Please Choose Type of Application
Dealership Name
Section A: Vehicle
Vehicle Condition Mileage
Vehicle Identification Number Year
Make Model
Engine Vehicle Has A/C P.S./P.B. A/T
List Other Equipment
Trade In Year
Make Model
Engine Vehicle Has A/C P.S./P.B. A/T
List Other Equipment
Mileage Other Charges:
Life/A & H-$
Other Charges:
Serv. Cont.-$		 Other Charges:
Other-$
Cash Price
Cash Down $ + Rebate $ =$
Trade-in Allowance Financed By
Owing on Trade
Net Trade-In
Total Down Payment
Unpaid Balance of Cash Price
Total of Other Charges to be Financed
Total Amount to be Financed For
#months
Insurance Information Insurance Company
Agent's Name Phone No.
Section B: Applicant
Applicant's Name (Last, First, Middle Init.) Have you ever filed bankruptcy? If yes, when?
Address City
State Zip Code
Home Phone E-Mail
Mortgage Company/Landlord Market Value
Mortgage Balance Time at Res (Years/Months)
Owning, Renting, Buying? Rent/Mortgage
Previous Address (City, State, Zip)
Time at Previous Residence (Years/Months) Date of Birth
Driver's Licence Number State
Expiration Date Name of Nearest Relative not in Household
Phone Number Relationship
Address (City, State, Zip)
Name of Another Relative not in Household Phone Number
Address (City, State, Zip)
Relationship
Employment Employer's Name
Employer's Address Business Phone Number
Occupation Time on Job (Yrs/Months)
Monthly Income Previous Employer Name
Previous Employer's Address
Occupation Time on Job (Years/Months)
Other Income Source(s) of other income: alimony, child support, or separate maintenance income need not be disclosed if you do not wish to have it considered as a basis for repaying this obligation.
Additional Monthly Income Source(s): (Washington)
Principals (To be completed if a Corporation or Partnership)
Type of Business State of Incorporation
Name of Principal / Applicant Title
Years? % of Ownership
Date of Incorporation Name of Principal / Applicant
Title Years?
% of Ownership
Credit References Include finance companies, banks, credit cards, charge accounts, suppliers.
WA: Indicate any other name(s) under which credit references and/or credit history may be verified.
Reference Name of Creditor /
Credit Card Co.

Address, Branch, Phone, or
Credit Card Number

 Open Closed
1st
2nd
3rd
Date Open High Term Payments
1st
2nd
3rd
Balance
1st
2nd
3rd
Prev. Car Financed or Leased With Prev. Acct. with Creditor? Bank or Savings Loan Accountant
Branch or Address Type of Account
Debts: List all debts including alimony,
child support, separate maintenance.
Use separate page if needed.		 $ per month
 Debts:
Section C: Joint Applicant or Other Party
Have you ever filed bankruptcy? If yes, when?
Joint Applicant or Other Party Name (Last, First, Middle Init.) Relationship
Date of Birth Social Security Number
Driver's Licence Number Driver's License State
 Expiration Date
Street Address City, State, Zip
Home Phone Number E-Mail
Mortgage Company/Landlord Market Value
Mortgage Balance Time at Residence (Years/Months)
Owning / Buying / Renting? Rent/Mortgage
Previous Address, City, State, Zip
Time at Previous Residence (Years/Months)
Name of Nearest Relative Not in Household Phone Number
Address, City, State, Zip
 Relationship
Name of Another Relative Not in Household Phone Number
Address, City, State, Zip
 Relationship
Employment Employer's Name
Employer's Address Business Phone Number
Occupation Time on Job (Years/Months)
Monthly Income
Previous Employer Name and Address
Previous Occupation Previous Time on Job (Years/Months)
Other Income Source(s) of other income: alimony, child support, or separate maintenance income need not be disclosed if you do not wish to have it considered as a basis for repaying this obligation.
Additional Monthly Income Source(s): (Washington)
Credit References Include fincance companies, banks, credit cards, charge accounts, suppliers.
WA: Indicate any other name(s) under which credit references and/or credit history may be verified.
Other Name:
Credit References Include finance companies, banks, credit cards, charge accounts, suppliers.
WA: Indicate any other name(s) under which credit references and/or credit history may be verified.
Reference Name of Creditor /
Credit Card Co.

Address, Branch, Phone, or
Credit Card Number

 Open Closed
1st
2nd
3rd
Date Open High Term Payments
1st
2nd
3rd
Balance
1st
2nd
3rd
Prev. Car Financed or Leased With Prev. Acct. with Creditor? Bank or Savings Loan Accountant
Branch or Address Type of Account
Debts: List all debts including alimony, child support, separate maintenance. Use separate page if needed. $ per month
 Debts:

California: An applicant, if married, may apply for a separate account.

Rhode Island, Maine, New York: A consumer report may be requested in connection with this application. Upon request, applicant will be informed whether or not a consumer report was requested, and if a report was requested, the name and address of the consumer reporting agency that furnished the report.

Ohio: The Ohio laws against discrimination require that all creditors make credit equally available to all creditworthy customers, and that all credit reporting agencies maintain separate credit histories on each individual upon request. The Ohio Civil Rights Commission administers compliance with the law.

New Hampshire: Applicants for balloon note contracts are entitled, upon request, to receive a written estimate of all the monthly payment amount for balloon payment refinancing in accordance with current refinance programs. These programs, however, are subject to change at any time.

Credit Report. Dealer, Chrystler Financial Company, L.L.C, DCFS Trust and/or __________________________________ (each, "Creditor") may obtain applicants' credit report in connection with this credit application, the credit transaction resulting from this application, or future extensions of credit by the Creditor, for any aspect of the credit transaction, including but not limited to reviewing the account, taking collection action, updating credit information or for any other Permissible Purpose under the Federal Fair Credit Reporting Act. Credit Investigation. I authorize the dealer and/or Creditor to start a credit investigation based on the information voluntarily provided by me which is true and correct, and reflects all my current debts. In addition, I authorize the Creditor to obtain federal and state records of employment and income history, including State Employment Security Agency ("SESA") records. The SESA authorization is for this transaction only and continues in effect for one (1) year unless limited by state law, in which case the authorization continues in effect for the maximum period, not to exceed one (1) year, as allowed by law. Bankruptcy. A bankruptcy proceeding is not in progress nor expected. Business Applications. If the application is submitted in the name of a business, a current and year end financial statement, including P&L statement, and balance sheet is required, audited if possible. Copy Provided. Upon request, I will be provided a copy of this application. Certification. Everything I have stated in this application is correct to the best of my knowledge.

Signature of Applicant
X_________________________________		 Date X__/__/__ Signature of Joint Applicant /
Other Party
X____________________________________		 Date X__/__/__

Because this form requires a signature, you must print out the form. Sign the printed copy and mail it, fax it, or bring it in to our business. If this document is not signed, we cannot process it.

Press Print to print this form. After pressing Print, you will go to a confirmation screen where you will be prompted to e-mail the form information to us. Please do so, so that we may help you further.


Also see
Click here for Automobility Connection online credit application, now available