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First name:
Last name:
Name or ID of Affiliate who referred you (if applicable):
City:
State/Province:
ZIP/Postal Code:
Have you ever lived in another State or Province? If so, which one(s)?
Are you planning on moving within the next 24 months?
If yes, where will you move?
Will you be promoted or change your place of employment within the next 24 months?
Email Address:
Daytime Phone:
Evening Phone:
Cellular Number:
Date of Birth:
Make of Vehicle:
Model of Vehicle:
Series of Vehicle:
(i.e. GT, LS, LX, etc.)
Year of Vehicle:
Insurance Company:
Insurance Policy Number:
Insurance Deductable:
Mileage:
Vehicle Condition:
Your Credit Rating:
Yearly Income:
Marital Status:
SSN/ SIN:
Work Start Date:
Spouse's SSN/ SIN:
Spouse's Work Start Date:
Loan Amount:
Maximum or Requested
Loan Amount:
Estimated Value of Vehicle:
Leased Vehicle?
Owned Vehicle?
Making Vehicle Payments?
Balance Owed on Vehicle:
Reason for Loan:
I have read and accept the BHM Arbitration clause

By submitting this application, I am certifying that the information provided in this credit application is accurate and true. I agree that I am fully responsible for all payment amounts due in repayment of my loan. I authorize BHM Financial Group to contact credit reporting agencies, financial institutions, past and present employers, and any other related source for the purpose of obtaining income and credit related information. I authorize the full disclosure of income and credit related information by these sources as is required for approval of financing, and I authorize these sources to accept this document as my written authorization to release any financial and/or credit related information to BHM Financial Group.

I agree that the information I have given BHM Financial Group on this application is complete and accurate and understand that BHM Financial Group is relying on the information. I understand that if I do not provide you with complete and accurate information on this application, I will have to repay any debt resulting from this application to you even if I become bankrupt.

In addition, I authorize BHM Financial Group to report all information provided to credit reporting agencies and to use the Information collected and to disclose the Information collected to credit reporting agencies and other parties.

All information provided and obtained is kept in the strictest confidence as and will never be released to any third parties unless it is in an effort to provide you with alternate financing or credit reporting.

I acknowledge that I may be required to provide additional document copies such as driver’s license for proof of identity, pay stubs for verification of income, proof of vehicle insurance and a recent telephone bill for confirmation of address.