PDF Nicholas Financial, Inc. Independent Dealer Application ...

Dealer's Name: Address: Finance Manager:

NICHOLAS FINANCIAL, INC.

INDEPENDENT DEALER APPLICATION

DBA:

Dealer License No.:

Phone No.:

Fax No.:

Email:

Legal Business Entity Type ? Check appropriate box and provide additional information:

Corporation

Date of Incorporation:

Limited Liability Company (LLC or PLLC) Date of Organization:

Partnership (including LLP, LP or General) Date of Registration or Establishment:

Sole Proprietor

How many years in business?

Dealer SSN/Federal TIN/ Federal EIN:

State Tax ID No.:

Is Dealer Bonded? Yes No Name of Surety Bond Company:

Bond Amt.:

Dealer Location (Check one): Owned By Dealer Leased

Lease Expiration Date:

VEHICLE INVENTORY INFORMATION

# of Units in Inventory:

Avg. # Miles on Inventory:

Avg. # of units sold per month:

Does Dealer run a vehicle history report on each vehicle in inventory? Yes No CarFax AutoCheck Other

Are the Units secured by a floor planner? Yes No Name of Floor Planner(s):

Does Dealer offer Service Contracts? Yes No

Name of Providers:

BANKING INFORMATION

********************* If the Dealer has been in business for less than one (1) year, Dealer must provide Nicholas

Financial, Inc. with the business' bank statements for the last four (4) consecutive months. *********************

PRINCIPALS/OWNERS PROFILES

Full Name:

Marital Status: Single Married Separated Divorced

SSN:

Date of Birth:

Spouse's Full Name:

Driver's License No.: Residence Address:

Percentage of Ownership: ____%

Title:

Full Name:

SSN: Driver's License No.: Residence Address:

Date of Birth:

Marital Status: Single Married Separated Divorced Spouse's Full Name:

Percentage of Ownership: _____%

Title:

Full Name: SSN: Driver's License No.:

Residence Address:

Date of Birth:

Percentage of Ownership: _____%

Marital Status: Single Married Separated Divorced Spouse's Full Name:

Title:

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NICHOLAS FINANCIAL, INC.

The undersigned certifies that the information herein is true and correct. If there is any material change in the information provided above, the undersigned agrees to notify NICHOLAS FINANCIAL, INC., ("NFI") in writing within 10 business days of such changes. NFI is hereby authorized to gather whatever credit and/or business history it deems necessary, and may contact any banks or financial institutions, insurance/bond carriers, the applicable Department of Motor Vehicles or other reporting services or state agencies to verify any information set forth above. The undersigned hereby authorizes parties so contacted to release information to NFI for purpose of establishing a business relationship and further authorize NFI to provide credit information about the undersigned to others. DEALER's Authorized Rep:

_________________________ ____________________ _____________________________ ______________

(Print Full Name)

Title

Signature

Date

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