First name: Last name: City: State/Province: ZIP/Postal Code: Email Address: Daytime Phone: Evening Phone: Cellular Number: Date of Birth: Make of Vehicle: Model of Vehicle: Series of Vehicle: (i.e. GT, LS, LX, etc.) Year of Vehicle: Insurance Company: Insurance Policy Number: Insurance Deductable: Mileage: Vehicle Condition: Select an option Excellent Good Fair Poor Your Credit Rating: Select an option Excellent Good Fair Poor Yearly Income: Marital Status: Select an option Married Single Divorced Common-law SSN/ SIN: Work Start Date: Spouse's SSN/ SIN: Spouse's Work Start Date: Loan Amount: Maximum or Requested Loan Amount: Select an option Maximum Amount Requested Amount Estimated Value of Vehicle: Leased Vehicle? Select an option Yes No Owned Vehicle? Select an option Yes No Making Vehicle Payments? Select an option Yes No Balance Owed on Vehicle: Reason for Loan: I have read and accept the BHM Arbitration clause Select an option Yes No By submitting this application, I am certifying that the information provided in this credit application is accurate and true. I agree that I am fully responsible for all payment amounts due in repayment of my loan. I authorize BHM Financial Group to contact credit reporting agencies, financial institutions, past and present employers, and any other related source for the purpose of obtaining income and credit related information. I authorize the full disclosure of income and credit related information by these sources as is required for approval of financing, and I authorize these sources to accept this document as my written authorization to release any financial and/or credit related information to BHM Financial Group. All information provided and obtained is kept in the strictest confidence as and will never be released to any third parties unless it is in an effort to provide you with alternate financing. I acknowledge that I may be required to provide additional document copies such as driver’s licence for proof of identity, pay stubs for verification of income, proof of vehicle insurance and a recent telephone bill for confirmation of address.

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