Welcome to Executive Mitsubishi, located in historic New Bedford, MA

Credit Inquiry Form

* fields are required
Your Contact Information
*First name
*Middle initial
*Last name
*Suffix
*Home phone
*Street
*City
*State
*Zip
Email


Co-Applicant Contact Information
First name
Middle initial
Last name
Suffix
Home phone
Street
City
State
Zip
Email

Your Application Information
*Social sec. #
*Birth date
*Employer
*Employer phone
*Annual salary
*Time at employer	yr mo
Additional Comments

Co-Applicant Application Information
Social sec #
Birth date
Employer
Employer phone
Annual salary
Time at employer	yr mo
Additional Comments

State-Required Disclosures

CALIFORNIA RESIDENTS:  A married applicant may apply 
for an individual account.

MAINE RESIDENTS:  Consumer reports (credit reports) 
may be obtained in connection with this application.

If you request, the creditor will inform you:  (1) 
whether or not consumer reports were obtained, and 
(2) if reports were obtained, the names and addresses 
of the consumer reporting agencies (credit bureaus) 
that furnished the reports.  You have the right to 
choose the agent and insurer for the insurance required
by this transaction, but the insurer must be approved by 
the creditor.

NEW YORK RESIDENTS:  A consumer credit report may 
be requested in connection with this application 
or in connection with updates, renewals, extensions
or enforcement of any credit granted as a result
of this application.  Upon your request, the 
creditor will inform you whether or not a consumer 
credit report was requested, and if so, the name 
and address of the agency that furnished such report.

OHIO RESIDENTS:  The Ohio laws against discrimination 
require that all creditors make credit equally available
to all credit worthy customers, and that credit 
reporting agencies maintain separate credit histories 
on each individual upon request.  The Ohio Civil Rights
Commission administers compliance with this law.

RHODE ISLAND RESIDENTS:  A consumer credit report 
may be requested in connection with this application.

VERMONT RESIDENTS:  I authorize the creditor to obtain 
credit reports on an ongoing basis about me from credit
reporting agencies in connection with this extension 
of credit transaction.  The creditor may obtain 
credit reports about me on an ongoing basis in 
connection with this extension of credit transaction
for any one or more of the following reasons: 
(1) reviewing the account;
(2) increasing the credit line on the account; 
(3) taking collection action on the account; or, 
(4) any other legitimate purposes associated 
with the account.

WASHINGTON RESIDENTS:  Please advise us if the creditor 
should investigate your credit references and/or credit
history under another name.  
 
MARRIED WISCONSIN RESIDENTS: No provision of a marital
property agreement, a unilateral settlement agreement
under Wis. Stat.?766.59, or a court decree under 
Wis. Stat. ?766.70 adversely affects the interest 
of the creditor unless the creditor, prior to the 
time the credit is granted, is furnished a copy of
the agreement, statement or decree, or has actual 
knowledge of the adverse provision.

ACKNOWLEDGMENT AND CONSENT: I certify that the above information is complete and accurate to the best of my knowledge. Creditors receiving this application will retain the application whether or not it is approved. Creditors may rely on this application in deciding whether to grant the requested credit. False statements may subject me to criminal penalties. I authorize the creditors to obtain credit reports about me on an ongoing basis during this credit transaction and to check my credit and employment history on an ongoing basis during the term of the credit transaction. If this application is approved, I authorize the creditor to give credit information about me to its affiliates.

Credit Inquiry Form

Your Contact Information

Co-Applicant Contact Information

Your Application Information

Co-Applicant Application Information