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Financing Application
Please enable JavaScript in your browser to complete this form.
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Step
1
of 4
Customer Information
Full Name
*
Nickname / Maiden Name
Email
*
Phone Number
*
Sex
*
-- Select Sex --
Male
Female
Married / Single
*
Married / Single
Married
Single
Current Address
Current Address
*
City / State
*
Zip code
*
How Long
*
Previous Address
Previous Address
*
Previous City / State
*
Previous Zip Code
*
Previous How Long
*
Drivers License
Drivers License
*
DL State
*
-- License State --
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
DOB
*
Next
Employer Information
Employer
*
Job Position
*
Hire Date
*
Work Address
*
Work Phone
*
Work Supervisor
*
Take Home Pay
*
Pay Period
*
-- Pay Period --
Weekly
Bi-Weekly
Monthly
Employment Type
*
-- Employment --
Full-Time
Part-Time
Temporary
Next Payday
*
Financial Information
Rent/House Payment
*
Rent or Own
*
Rent or Own?
Rent
Own
Paid To
*
Landlord Phone
Bills Paid Monthly
*
Home / Cell Phone
Cable / Satellite
Utility Bills
Furniture
Credit Card(s)
Bank Information
Bank
*
-- Select Bank --
Bank of America
Wells Fargo
Citibank
Chase
US Bank
Sun Trust
Capital One
Other
Other Bank
*
Branch Location
*
Bank Account Type
*
-- Bank Account Type --
Checking
Savings
Other
Account Number
*
Next
Automobile Information
Automobile Year
*
Automobile Make
*
Automobile Model
*
License Tag
*
Registered Owner(s)
*
VIN #
*
Payment Amount
*
Next Payment Due Date
*
Purchase Date
*
Lienholder
*
Lienholder Phone
*
Lienholder Account #
*
Insurance Company
*
Insurance Phone
*
Coverage Type
*
Full
Liability
None
Monthly Payment
*
Policy #
*
Next
Personal References
Name (1)
*
Address (1)
*
Relationship (1)
*
Phone (1)
*
Name (2)
Address (2)
Relationship (2)
Phone (2)
Release of Information (Please read the following statement before signing)
Customer Signature
*
Clear Signature
You certify that the information you have provided on this Customer Order Form is true and correct. You understand that if any of the information you provided is found to be false this order may be rejected. By signing below, you agree that we or our agents can contact you about your account with us via email, telephone (including cell phones), or text messages at any email address or phone number you have given us, even if you are charged for the call. You also agree that we can contact you with special offers and other marketing information with these methods. You agree that we may use automatic dialing systems or pre-recorded messages. You certify that the number(s) you have given us for phone(s) that belong to you. Consent to receive special offers and marketing information is not a condition of purchase/rental. You can cancel your consent to get automatic dialing calls or pre-recorded messages by notifying us by any email at sales@pimparim.com, or calling us at (305) 956-8356. You also agree that, from time to time, we may monitor telephone conversations between you and us to assure the quality of our customer service. You also agree to notify us promptly if you change any of the phone numbers you have given us. I hereby acknowledge that I have read and understand the statement above and certify that I am eighteen (18) years of age or older and I am able to enter into any legally binding agreement.
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