Business Credit Application

[Pages:1]Business Credit Application

A. Dealer Information

Dealer Name

Vendor ID #

Phone # Email Address

Contact Name Fax #

B. Applicant Information (Submit application for each entity expected to use line)

Company Name

Tax ID #

Company Address

Email Address

Contact Name Phone #

C. Indicate Type of Business

Sole Proprietorship c Partnership c Corporation c Other c

Non-Profit Organization c Yes c No

D. CO-APPLICANT INFORMATION

Last Name

First Name

Middle Initial

Social Security Number

Birth Date

Address

Apt#/Suite # P.O. Box

Rural

City

Route

State Zip

Home Phone Cell Phone

Residential Status

q Homeowner

q Rent

q Family

q Other

How Long? Rent/mtg. Pmt. $ ___Yrs. __Mos.

Email Address

Driver's License Number

Driver's License State

Time at Prior Address _____Yrs. ____Mos.

Previous Full Address (If less than 2 years)

Apt#/Suite # P.O. Box

Rural Route City

State Zip

Employer Name

Salary

Salary Type q Weekly q Bi-Weekly

Previous Employer Name

Employment Type q Employed q Unemployed q Self-Employed

q Monthly q Annually

Occupation

Previous Employment Type q Employed q Unemployed q Self-Employed

q Military q Retired q Student q Other Length of Employment Work Phone _____Yrs. ____Mos.

q Military q Retired q Student q Other

Previous Occupation

Length of Employment _____Yrs. ____Mos.

Previous Work Phone

Alimony, child support or separate maintenance income need not be revealed if you do not choose to have it considered as a basis for repaying this obligation.

Other Income (monthly)

Source of Other Income

Comments

D. 12-Month Delivery Forecast Replacement Vehicles # ____________ Additional Vehicles # _______________ Average Vehicle Price $ ____________ Expected Delivery Date ___________________________________________________________________________________ USA Patriot Act Notice -- IMPORTANT INFORMATION ABOUT NEW ACCOUNT PROCEDURES To help the United States Government fight terrorism and money laundering, Federal Law requires us to obtain, verify and record information that identifies each business or entity, which opens an account or establishes a relationship. For you, this means: when you open an account or establish a relationship, we will ask for your business name, a street address and a tax identification number or other documents that will assist us to identify and verify your business. The undersigned applicant irrevocably and continuously authorizes Santander Consumer USA dba Chrysler Capital to obtain from and provide to third persons any and all types of information concerning the applicant, including, without limitation, credit, financial and business information.

Signed __________________________________________, 2013 _______________________________________________ Legal Name of Applicant

By ______________________________________ _______________________________ ____________________________

Signature

Name

Title

? 2013 CHRYSLER CAPITAL. Chrysler Capital is a trademark of Chrysler Group LLC and licensed to Santander Consumer USA Inc. CC-FLT_30521_052813

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