KMC Finance Application

Name?*

First Name

Initial

Last Name

Address?*

Address Line 1

Address Line 2

City

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?*

Years at current address?*

Months at current address?*

Previous address?*

Address Line 1

Address Line 2

City

State

ZIP Code

Years at previous address?*

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?*

Enter as mm/dd/yyyy

Social Security Number?*

Number only, no spaces

Do you have a Drivers License?*

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

State

ZIP Code

Employers Phone Number?*

(555)555-5555

Employment is?*

Years at current job?*

Months at current job?*

Occupation \ Job Description*

Gross Monthly Income?*

Before tax

Previous Employer?*

Years at previous job?*

Months at previous job?*

Previous Occupation \ Job Description*

Do you have other monthly income?*

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?*

Where is it financed?*

Enter the name of the bank or other lender payment is made to.

Will you be trading this vehicle in?*

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?

Select Salesperson*

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?*

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

Kirksville Motor Company Secure Online Pre-Qualification Form

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