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Kirksville Motor Company Secure Online Pre-Qualification Form
Please fill out your information below. Your information is being submitted securely.
Name?
*
First Name
*
Initial
*
Last Name
*
Address?
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
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
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands (US)
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces (the) Americas
Armed Forces Europe
Armed Forces Pacific
Army Post Office (U.S. Army and U.S. Air Force)
Fleet Post Office (U.S. Navy and U.S. Marine Corps)
State
ZIP Code
Email address?
*
name@name.com
Do you have a Home Phone?
*
Yes
No
Home phone number?
*
(555)555-5555
Do you have a Mobile\Cell Phone?
*
Yes
No
Mobile phone number?
*
(555)555-5555
Residence?
*
Own Home
Living with Relatives
Renting\Leasing
Years at current address?
*
Select One
less than 2
2
3
4
5
6
7
8
9
More than10
Months at current address?
*
Select One
23
22
21
20
19
18
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
Previous address?
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
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
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands (US)
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces (the) Americas
Armed Forces Europe
Armed Forces Pacific
Army Post Office (U.S. Army and U.S. Air Force)
Fleet Post Office (U.S. Navy and U.S. Marine Corps)
State
ZIP Code
Years at previous address?
*
Select One
1
2
3
4
5
6
7
8
9
More than10
Mortgage payment?
*
Mortgage Holder?
*
Enter the name of who you make your monthly payment to.
Mortgage Balance?
*
Enter the approximate amount you still own on your home.
Monthly Rent amount?
*
Enter the $ amount you pay monthly for rent.
Landlord?
*
Who do you pay your rent to?
Date of Birth?
*
https://kirksvillemotors.formstack.com/forms/images/2/calendar.png
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
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02
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06
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23
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28
29
30
31
Year
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
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1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
Enter as mm/dd/yyyy
Social Security Number?
*
Number only, no spaces
Do you have a Drivers License?
*
Yes
No
Select One
Select Yes or No
Drivers License number?
Enter your Drivers License number
State of issue?
*
Enter the State your Drivers License is issued in, example MN ND SD
Current Employment Status
*
Currently Employed
Retired
Currently Unemployed
Source of Income while Unemployed?
*
Source of Retirement Income?
*
Current Employer?
*
Current Employer address?
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
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
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands (US)
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces (the) Americas
Armed Forces Europe
Armed Forces Pacific
Army Post Office (U.S. Army and U.S. Air Force)
Fleet Post Office (U.S. Navy and U.S. Marine Corps)
State
ZIP Code
Employers Phone Number?
*
(555)555-5555
Employment is?
*
Full-time
Part-time
Years at current job?
*
Select One
2 years or less
3
4
5
6
7
8
9 or more years
Months at current job?
*
Select One
23
22
21
20
19
18
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
Occupation \ Job Description
*
Gross Monthly Income?
*
Before tax
Previous Employer?
*
Years at previous job?
*
Select One
Less than 2 years
2
3
4
5
6
7
8
9 or more years
Months at previous job?
*
Select One
23
22
21
20
19
18
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
Previous Occupation \ Job Description
*
Do you have other monthly income?
*
No
Yes
Other Monthly Income?
*
Amount of other income $
Source of other income?
*
Example - part-time job, investments, etc.
Where do you bank?
*
Enter the name of your Bank, enter NONE if you don't have any bank accounts.
Accounts at current bank?
*
Checking
Savings
Loans
Do you have a vehicle loan now?
*
Select One
Yes
No
Where is it financed?
*
Enter the name of the bank or other lender payment is made to.
Will you be trading this vehicle in?
*
Select One
Yes
No
What is the Model Year of your trade-in?
*
What is the Make of your trade-in?
*
What is the Model of your trade-in?
*
What is your loan payoff?
*
Enter the approximate amount needed to pay your loan back in full.
Cash Down?
*
How much cash will you be putting down?
Vehicle You Are Shopping For?
*
What is the specific or type of vehicle you are wanting to buy?
Have you been working with a salesperson at Kirksville Motor Company?
No
Yes
Select Salesperson
*
Tonya Beaty
Jim Brown
Randy Cowan
Jon Hurd
Brianna Mackesty
Remy Ndiang
Camron Powell
Duncan Simmons
Alex Wood
Kaden Anderson
Bill Vaughn
Kaine Slaughter
Ryan Stufflebean
Dan Anderson
Tyson Yos
Brandon Paxton
Other - Not Listed
Select a name from the list or select other and enter a name.
Please enter the name of the person you have been speaking with.
*
Do you have a co-applicant?
*
No
Yes
I understand a representative from Kirksville Motor Company will inquire with the credit reporting agencies about the status of my credit file and may submit this information to various lenders for credit approval.
*
Yes
Next Step
Does your Co-Applicant know you are submitting this information?
*
Yes
No
Co-applicant's name
*
First Name
*
Initial
*
Last Name
*
Relationship of co-applicant to you?
*
Spouse
Parent
Brother \ Sister
Fiancée
Friend
Other
Does the co-applicant live with you?
No
Yes
Address of co-applicant?
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
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
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands (US)
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces (the) Americas
Armed Forces Europe
Armed Forces Pacific
Army Post Office (U.S. Army and U.S. Air Force)
Fleet Post Office (U.S. Navy and U.S. Marine Corps)
State
ZIP Code
Co-applicant's Date of Birth?
*
https://kirksvillemotors.formstack.com/forms/images/2/calendar.png
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Day
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Year
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
Enter as mm/dd/yyyy
Does the Co-applicant have a Drivers License?
*
Yes
No
Select One
Select Yes or No
Co-applicant's Drivers License number?
*
Enter your Drivers License number
Co-applicant's Social Security Number?
*
Number only, no spaces
Co-applicant's Current Employment Status?
*
Currently Employed
Retired
Currently Unemployed
Does the co-applicant have a source of income?
*
Yes
No
Co-applicant's Source of Income?
*
Co-applicant's Current Employer?
*
Co-applicant's Occupation \ Job Description?
*
Co-applicant's Current Employer address?
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
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
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands (US)
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces (the) Americas
Armed Forces Europe
Armed Forces Pacific
Army Post Office (U.S. Army and U.S. Air Force)
Fleet Post Office (U.S. Navy and U.S. Marine Corps)
State
ZIP Code
Co-applicant's Employer Phone Number?
*
(555)555-5555
Co-applicant's employment is?
*
Full-time
Part-time
Co-applicant's Years at current job?
*
Select One
less than 1
1
2
3
4
5
6
7
8
9
10
More than10
Co-applicant's months at current job?
*
Select One
1
2
3
4
5
6
7
8
9
10
11
Co-applicant's previous job?
*
Gross monthly Income of co-applicant?
*
Before tax.
Does co-applicant have any other income?
*
No
Yes
Other monthly income?
*
Co-applicant's amount of other income $
Co-applicants Phone?
Co-applicant's Email?
I understand a representative from Kirksville Motor Company will inquire with the credit reporting agencies about the status of my credit file and may submit this information to various lenders for credit approval.
*
Yes
Message?
Please write any other information you would like us to know.
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