Personal Pre-Qualification Questionnaire

PERSONAL PRE-QUALIFICATION QUESTIONNAIRE

This Personal Pre-Qualification Questionnaire is used to collect information for an initial assessment of eligibility for personal credit, financing, or other services. Completion of this questionnaire does not constitute approval or a binding commitment. Information provided will be relied upon for preliminary evaluation and may be verified. Applicant must certify accuracy below.

Applicant Information

Date of Birth:

Primary Phone:    Email:

Own    Rent    Live with family    Other (specify below)

Employment and Income

Employer Address:

Length of Employment:

Assets, Liabilities & Credit

Bankruptcy in past 7 years    Foreclosure or deed-in-lieu    Accounts in collections    Civil judgments against me    None of the above

Requested Financing

Desired Term:    Estimated Monthly Payment:

Consent, Certification and Authorization

By checking the authorization box below and signing this questionnaire, I certify under penalty of perjury that the information provided in this form is true, complete and accurate to the best of my knowledge. I understand that this pre-qualification is preliminary, non-binding, and does not constitute an approval or commitment to lend or provide services. I agree that the information provided may be used to perform reasonable verification of my identity, employment, income, assets and credit history.

I authorize the recipient of this questionnaire and its agents to obtain consumer credit reports and to contact references, employers, financial institutions, and credit bureaus to verify any information contained herein. I further authorize the release of information about my account performance to other creditors and credit reporting agencies as required for verification.

I authorize verification and credit inquiries as described above.

I understand that intentionally providing false information may be unlawful and may result in denial of pre-qualification or termination of processing. I also understand that any preliminary estimate of terms, interest rate, or amount provided as a result of this questionnaire may change following verification of documentation and a full underwriting review.

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