SamsonMotors.com - Warranty

Please tell us about yourself

First Name:
Middle initial:
Last Name:
E-Mail address:
Suffix:	Jr. Sr. Other - please enter:
Date of birth:
Drivers license state and number:	State: Number:
Address:
City:
State:
Zip Code:
Do you have a phone in your home?:	Yes No
Phone Number:
Social Security number:
Level of Education (for ages 18-27 only):	Some high school High school graduate Some college Special training 2-Year college graduate 4-year college graduate

Please tell us about the vehicle you would like to purchase
If you would like preview our inventory, please click here. Our inventory department will
appear in a new browser. When you are finished, you can simply close that browser and return here.

I would like to purchase:	Vehicle in stock I have a special request I would like to know what I am qualified for first
If in stock, which vehicle?:
If it is a special request, please give us some details:

Please tell us about your home

Do you own or rent your home?:	Renting/leasing Own home outright Buying home Living with relatives Own/buying mobile home
How long have you lived there?:	Years: Months:
Landlord or Mortgage Holder Name:
Landlord or Mortgage Holder Phone:
Current mortgage balance:
Present value of home:
Rent/mortgage payment monthly:
Previous Address/City/State/Zip:
Previous Landlord phone number:

Please tell us about your employment/income

Your occupation:
Employer name:
Employer address:
Employer phone:
How long have you worked on this job?:	Years: Months:
Gross weekly salary:
Any source of other income?:	Yes No
If so, what is the source? (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):
Gross income from this source:
Previous Employer (if less than 3 years on present job):
Previous employer address/city/state/zip:
Previous employer phone number:

Please tell us about your credit history

Name of bank
Account type:	Savings Checking Savings and Checking No account
Name of second bank:
Account type:	Savings Checking Savings and Checking No account
Have you ever had a car or other merchandise repossessed?:	No Yes - If Yes, when?:
Have you ever filed for bankruptcy?:	No Yes - If Yes, chapter?: Date Filed: Date Discharged:
Are you obligated to make alimony, child support or separate maintenance payments?:	No Yes - If Yes, amount?:
Have you ever financed or leased a vehicle?:	No Yes If Yes, please describe:
Do you have any credit cards?:	No Yes If Yes, please list your cards:

If you are applying in your name only, please click here
and then click the Submit button below.

If you are applying with a joint applicant, please continue
with the form below and then Submit.

Joint Applicant's information (if applicable)

First Name:
Middle initial:
Last Name:
Suffix:	Jr. Sr. Other - please enter:
Date of birth:
Drivers license state and number:	State: Number;
Social Security number:
Your occupation:
Employer name:
Employer address:
Employer phone:
How long have you worked on this job?:	Years: Months:
Gross weekly salary:
Any source of other income?:	Yes No
If so, what is the source? (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):
Gross income from this source:
Previous Employer (if less than 3 years on present job):
Previous employer address/city/state/zip:
Previous employer phone number:

By submitting this form, you certify that the above information is true and complete to the best of your knowledge. You further certify that you and any joint applicant have attained the age of majority. You and any joint applicant authorize Samson Motors, Inc. and or its assigns to to check your credit and employment history and to provide or obtain information about credit experiences with you. You understand that all financing is subject to credit approval for qualified buyers.

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