Personal Info
Prefix
M.I.
First Name*
Last Name *
Social Security #*
D.O.B.*
Which Location is more
Convenient to you?
Residence & Contact Info
Address*
City*
State *
ZIP*
Mortgage or Rent,
($)/Mo.
*
How Long at Current
Address?
*
Rent /
Own?
Yrs*
Mos*
Phone # *
Email Address*
Name of salesperson you are working with -
(if none, enter "none" in the text box)
*
Employment Info
Employment Status *
Occupation*
Employed By *
Business
Phone #
*
Yrs
Time Employed *
Mos
Salary
Type
*
Gross Salary *
If Under 2 Years,
Previous Occupation:
Employed By
Business
Phone #
Time
Employed
Gross Salary
Mos
Yrs
Complete "Other Income" and "Source of Other Income" only if you want this income
considered for repayment.
Enter monthly amount. Alimony, child support or separate maintenance income need not be
revealed if you do not wish to have it considered as a basis for repaying this obligation.
Other Income -
Monthly
Other Income -
Source
Vehicle Information
Vehicle of Interest  -  Make:
Model
Trade In? *
Year
Make
Model
Mileage
Trade in VIN
Loan Information
Cash Down? ($)
Amt to finance, $
Buy / Lease
Loan Terms
Payment / Mo.
Please type "Y" to indicate you have
read and agree to our
privacy notice
By clicking "SUBMIT" I certify the above information is complete and accurate.  I am authorizing Ray Laks Acura to
investigate my credit and employment history and to release information about Ray Laks Acura's credit experience with
me.  Upon request I will be informed whether a credit report was requested and the name of the consumer reporting
agency that furnished the report.  Additional consumer reports may be requested with respect to any extension or
renewal of this obligation.