AUTO CASH TITLE LOANS
PERSONAL INFORMATION

Date ________

How did you hear about us? Internet Dex Yellow book Tuscon page Drive by Referred by

APPLICANT’S INFORMATION        Married, Single, separated, other ____

Applicant’s Name: ____________________________________________________SS# ______________D.O.Birth ___ ___ ___
                               LAST                           FIRST               M.I

Co-Applicants Name: ____________________________________________________SS# ______________D.O.Birth ___ ___ ___
                                 LAST                     FIRST                M.I

Home Address: _______________________________________________Apt. / Sp. # _______ City, State, Zip:  ______________________________________

Mailing Address: _______________________________________________Apt. / Sp. # _______ City, State, Zip:  ____________________________________

Home Phone: (___)_________________Cellular Phone: (___) _______________ Pager: (___)________________

How long at this address? ____/____   ( )  Own    ( )   Rent   ( )   Rent lot/Space   ( )  Lives with other (s)-Whom:_____________________________________

Landlord or Mortgage: _________________________ Landlord’s Phone: (    )_________________ Mo. Pmt.: $_______________

Other Previous Address:  __________________________________________________________________
City, State, Zip: _________________________________________________________________________ How long? ______________

How Long Living in this area? Applicant: _____________Co-Applicant:______________ # of Children living with you: _________

EMPLOYMENT INOFMATION

Applicant’s Employer: ____________________________________ Address: ____________________________

Work Phone: (___)________________ Position: ___________________ Supervisor: ______________________ How long at this job? _________

Monthly Gross Income: $ _______________ Other income (s): $__________Source:_______________________

Previous Employer: ______________________________________Position: _____________________________
City, State: _____________________________________________How long? ___________________________

Co-Applicant’s Employer: _____________________________________Address:______________________________________________

Work Phone: (____) ___________________ Position: ________________ Supervisor: _________________ How Long? ________

Monthly Gross income: $ _________________ Other income(s); $ ______________________ Source: _____________________________

Previous Employer: ____________________________ Position: ____________ City, State: ____________ How long? _________

REFERENCES (Prefer nearest relative(s) not living with you)

Name: __________________________ Address: ________________________City, State, Zip:______________

Phone: ( )____________________________Relationship: _________________________________________
To Applicant       To Co-Applicant

Name: ________________________ Address: __________________________ City, State, Zip: _______________

Phone: ( )___________________________ Relationship: __________________________________________
To Applicant       To Co-Applicant

Name: ____________________________ Address: _________________________ City, State, Zip: __________

Phone: ( ) _________________________ Relationship: ___________________________________
To Applicant       To Co-Applicant

Have you ever filed bankruptcy before? No _________ Yes _________ When ______________ Chapter _________

Are you in the process filing or considering filing bankruptcy? No. _______ Yes ________ When ___________ Chapter ___________

I, AUTHORIZE AUTO CASH TITLE LOANS TO VERIFY MY EMPLOYMENT, CONTACT MY LANDLORD, PERSONAL REFERENCES, OBTAIN A CREDIT REPORT, AND USE ANY OTHER MEANS AVAILABLE TO VERIFY THE ACCURACY OF THE ABOVE INFORMANTION.

Signature: ______________________________________      Date: ____________________________

Signature: ______________________________________      Date: ____________________________