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First Name*

Last Name*

Email Address*

Phone #*

Street Address*

Address line 2

City*

State*

Zip Code*

Date of Residency

This is the date you started living at your current residence

Monthly Rent/Mortgage*

Social Security #*

Date of Birth*

Employment info

Employer Name

Employer Phone #

Gross Monthly Income*

Additional Income

Date of Employment

Tell us about the vehicle you want

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Make

Model

Trim

Total Loan Amount*

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I agree to give permission for the above applicant(s) Consumer Credit Report(s) to be obtained, at no cost to me, in order to help determine the types and extent of financing which are available*

In connection with your transaction, Payton Select may acquire information about you as described in this notice, which we handle as stated in this notice.

We may collect personally identifiable information such as name, postal address, telephone number, e-mail address, social security number, date of birth, etc. This personal information is collected and used by Payton Select Credit Application staff for the purpose of facilitating a relationship or business transaction.

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