Potamkin Automall Credit Application

* Required

This secure form will start the credit verification process. Fields marked * are required.

Applicant Information

First Name *

Middle Initial

Last Name *

Suffix

Date of Birth *

Social Security Number *

Email *

Address *

City *

State *

ZIP *

Housing Information

Length of Residence *

Housing Status *

Mortgage/Rent Amount *

Landlord or Mortgage Holder *

Previous Address *

Previous City *

Previous State *

Previous ZIP *

Previous Length of Residence *

Previous Rent or Mortgage Amount *

Employment Information

Employer *

Occupation *

Employer Phone *

Gross Monthly Income *

Time Employed *

Previous Employer *

Previous Occupation *

Previous Employer's Phone

Previous Gross Monthly Income *

Previous Time Employed *

Your Current Auto Loan

Make/Model

Signature & Privacy Statement

Signature *

Date *

* Required

By submitting this credit application, I verify that the information provided is complete and accurate to the best of my knowledge. I further authorize an investigation of my credit and employment history. I also accept the terms of the Privacy Policy.

Potamkin Chevrolet