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MULTI-STATE APPLICATION - A credit report may be obtained in connection with your application.
IMOPORTANT NOTICE: To obtain of the Credit Acceptance Corporation Privacy Policy, please call toll-free (870) 288-6357
Individual Applicant
Joint Applicant for
APPLICATION
Toll Free: 800-351-5524
FAX No: 860-355-2842
CUSTOMER CONTACT INFORMATION
Best Time to Call Primary Phone
8am - 12noon
12noon - 4pm
4pm - 8pm
Cell Phone #
Home Phone #
Other Phone # (Relative, Friend, etc.)
CUSTOMER INFORMATION
Last Name
First Name
Middle Name
Maiden Name
Social Security #
Date of Birth
(MM/DD/YYYY)
RESIDENCE INFORMATION
How long at address?
Yrs
Mos
Address No
Street Name
Apt #
City
State
Zip Code
Person who's name appears on residence utilities
MAILING INFORMATION
Address No
Street Name
Apt #
City
State
Zip Code
Own/Rent?
Own
Rent
Monthly Pmt
Landlord Name
Landlord Address
Landlord Phone
PREVIOUS ADDRESS INFORMATION
Address No
Street Name
Apt #
City
State
Zip Code
How long at prev?
Yrs
Mos
PRIMARY EMPLOYMENT
Employer Name
Dept or Military Rank (if applicable)
Occupation
Address No
Street Name
Apt #
Phone #
Extension
City
State
Zip Code
Supervisor
Monthly Income (Gross)
Pay Frequency
Wk
Bi
2 Wks
Mth
Work Schedule
6am - 3pm
9am - 6pm
12 noon - 9pm
3pm - 12 midnight
12 midnight - 9am
Hire Date
(MM/DD/YYYY)
SECONDARY EMPLOYMENT
Employer Name
Occupation
Work Schedule
6am - 3pm
9am - 6pm
12 noon - 9pm
3pm - 12 midnight
12 midnight - 9am
Hire Date
(MM/DD/YYYY)
Address No
Street Name
Apt #
Phone #
Extension
City
State
Zip Code
Supervisor
Monthly Income (Gross)
Pay Frequency
Wk
Bi
2 Wks
Mth
Previous Employer
Years on Job
Yrs
Mos
Address No
Street Name
Apt #
City
State
Zip Code
OTHER INCOME
**Other Income Source
**Amount and Frequency of Other Income
**Alimony, child support or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.
BANK INFO
Savings Account
Yes
No
Checking Account
Yes
No
Name
Location
California Applicant:
If you are married, you may apply for a separate account.
Ohio Applicants:
The Ohio laws against discrimination require that all creditors make credit equally available to all credit worthy customers, and that credit reporting agencies maintain separate credit histories on each individual upon request. The Ohio Civil Rights Commission administers compliance with this law.
Maine Applicants:
You are required by the terms of the con.You have the right to free choice in the selection of the agent and insurer through or by which the insurance is to be placed, including the right to choose an agent or broker whether or not that agent or broker is affiliated with the creditor. Obtaining insurance products from a particular agent or broker does not affect credit decisions by the creditor. Obtaining insurance products from a particular agent or broker does not affect credit decisions by the creditor regarding you, unless the insurance product violates the terms of the extension of credit regarding the adequacy of coverage or is otherwise not approved by the creditor.
New York Applicants:
In connection with your application for the credit, a consumer report (credit report) may be requested. On your request, we will advise you if the report was actually ordered, and if so, the name and address of the agency that furnished the report.
WISCONSIN RESIDENTS ONLY:
Notice to Married Applicants: No provision of any marital property agreement, a unilateral statement under Wis. Stat. § 766.59 or a court decree under Wis. Stat. § 766.70 adversely affects the interest of the creditor unless the creditor, prior to the time the credit is granted, is furnished a copy of the agreement, statement or decree or has actual knowledge of the adverse provision when the obligation to the creditor is incurred.
The credit being applied for, if granted, will be incurred in the interest of my marriage or family. I understand that the creditor may be required by law to give notice of the credit transaction to my spouse.
I acknowledge that pursuant to the
Fair Credit Reporting Act
, my application will be submitted to Credit Acceptance Corporation, a Michigan corporation, and/or any of its affiliates or subsidiaries or divisions ("Credit Acceptance") for review in connection with the assignment of a sales finance contract written, or to be written, in connection with my purchase.
I certify that the above information is complete and accurate. In connection with this application, I authorize and give Seller and Credit Acceptance my consent to obtain my credit report from any Credit Reporting Agency and complete an investigation of my credit and employment history and release information about my credit experience with Seller and/or Credit Acceptance. If and after my contract is assigned to Credit Acceptance, I also authorize and give consent to Credit Acceptance to obtain my credit report from any Credit Reporting Agency at any time during the term of my contract for any purpose whatsoever, including but not limited to for prescreening, as defined and permitted from time to time by the Federal Trade Commission; for reviewing my contract; to defer or extend my payments or due date under my contract; to take collection action on my contract; or for other legitimate purposes associated with my contract. I understand and acknowledge that Credit Acceptance will retain this application whether or not it is approved. I also understand and acknowledge that if I ask, I will be informed if a credit report has been requested in connection with this application for credit, and the name and address of the Credit Reporting Agency that furnished the report.
*Email Communication:
By signing below I authorize and give consent to Credit Acceptance to use the email address I have provided on this application to communicate with me for any purpose whatsoever, including but not limited to communications regarding my account activity, status and collections.
Spousal Consent:
By signing below I authorize and give consent to Credit Acceptance to discuss my account with my spouse, if applicable, including discussing my account activity, status and payment arrangments.
NEW MILFORD 860-354-5524 / 1-800-351-5524 / FAX-860-355-2842
KENT 860-927-4142 / 1-800-900-4042 / FAX-860-927-3183
