Credit Application

What year/make/model vehicle are you interested in purchasing?

Credit Type
Individual Credit

-- applying for credit in your own name and relying on your own income or assets and not the income or assets of another person as the basis for repayment of the credit requested.

Joint Credit

-- applying for joint credit with another person. Relationship to joint applicant or other party, if any:

Name:

Individual Credit

-- applying for credit in your own name but relying on income from alimony, child support or separate maintenance or on the income or assets of another person as a basis for repayment of the credit requested.

Business Application    Previous GMAC or Mitsubishi Diamond Credit

Last Name or Business Name:

First Name: MI:

Social Security Number (or TAX ID):

Date of Birth:

Preferred e-mail address:

Home Phone:

PO Box Number:

Current Street and Apt./Suite Number:

City: State: Zip:

Years and Months At This Address:

Own?

Rent?

Mortgage Payment or Rent per month:

Employed By or Type of Business (if business application):

Occupation:

Business Phone:

Total Gross Annual Income:

Years/Months Employed:

Military Rank:

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.

Nearest relative or friend not living with you:

Home Phone: PO Box Number:

Current Street and Apt./Suite Number:

City: State: Zip:

This application will be submitted to GMAC or Mitsubishi Diamond Credit or (and) at Nationstruck.com, 434 Winchester St., Keene, NH 03431 so that GMAC Mitsubishi Diamond Credit (and) may decide whether or not to purchase the transaction.

I certify that the information in my application is complete and true. I authorize the dealer and GMAC or Mitsubishi Diamond Credit to investigate my credit and employment history, obtain credit reports, and release information about their credit experience with me. I also authorize the dealer and GMAC or Mitsubishi Diamond Credit (and) and their affiliates and marketing associates to use information about me, including information in my application, for marketing and administrative purposes. I certify that I have read and agree to the above privacy policy.

Applicant and other party signatures:
Date:

If you are ready to buy, what is your deposit amount?: $

VISA    MasterCard American Express GM Card

Cardholder name:

Credit Card Number:

Expiration Date:

In connection with your transaction, Nationstruck.com may obtain information about you as described in this notice, which we handle as stated in this notice.

We collect nonpublic personal information about you from the following sources:
Information we receive from you on applications or other forms;
Information about our transactions with us, our affiliates or others; and,
Information we receive from consumer reporting agencies.

2. We may disclose all of the information we collect, as described above, to companies that perform marketing services on our behalf or to other financial institutions with whom we have joint marketing agreements. We may make such disclosures about you as a consumer, customer, or former customer.

3. We may also disclose nonpublic personal information about you as a consumer, customer, or former customer, to non-affiliated third parties as permitted by law.

4. We restrict access to nonpublic personal information about you to those employees who need to know that information to provide products or services to you. We maintain physical, electronic, and procedural safeguards that comply with, federal regulations to guard your nonpublic personal information.


CUSTOMER ACKNOWLEDGEMENT: I (we) acknowledge that I (we) received a copy of this notice on the date indicated below.


____________________________ _______________
Customer's Signature Date

____________________________
Customer's Name (printed)

____________________________ _______________
Co-customer's Signature Date

____________________________
Co-customer's Name (printed)

Please sign and fax privacy form to 1-603-283-1062, or mail to Peter Dragon, Nationstruck.com Finance, 434 Winchester St., Keene, NH 03431

Federal law requires that we receive this signed form before processing any private information.