Credit Application

Applicant Information

Name:

Date of birth:

SSN:

Phone:

Current address:

City:

State:

ZIP Code:

Own     Rent    (Please circle)

Monthly payment or rent:

How long?

Previous address:

City:

State:

ZIP Code:

Owned Rented            (Please circle)

Monthly payment or rent:

How long?

Employment Information

Current employer:

Employer address:

How long?

Phone:

E-mail:

Fax:

City:

State:

ZIP Code:

Position:

Hourly Salary (Please circle)

Annual income:

Previous employer:

Address:

How long?

Phone:

E-mail:

Fax:

City:

State:

ZIP Code:

Position:

Hourly Salary  (Please circle)

Annual income:

Name of a relative not residing with you:

Address:

Phone:

City:

State:

ZIP Code:

Relationship:

Co-Applicant Information, if for a joint account

Name:

Date of birth:

SSN:

Phone:

Current address:

City:

State:

ZIP Code:

Own     Rent    (Please circle)

Monthly payment or rent:

How long?

Previous address:

City:

State:

ZIP Code:

Owned Rented            (Please circle)

Monthly payment or rent:

How long?

Employment Information

Current employer:

Employer address:

How long?

Phone:

E-mail:

Fax:

City:

State:

ZIP Code:

Position:

Hourly Salary (Please circle)

Annual income:

Previous employer:

Address:

Phone:

E-mail:

Fax:

City:

State:

ZIP Code:

Position:

Hourly Salary (Please circle)

Annual income:

Application Information Continued

Name of a relative not residing with you:

Address:

Phone:

City:

State:

ZIP Code:

Relationship:

Credit Cards

Name

Account no.

Current balance

Monthly payment

Mortgage Company

Account no.:

Address:

Auto Loans

Auto loans

Account no.

Balance

Monthly payment

Other Loans, Debts, or Obligations

Description

Account no.

Amount

Other Assets or Sources of Income

Description

Amount per month or value

I authorize Undercover Motorsports, Inc. to verify the information provided on this form as to my credit and employment history.

Signature of applicant

Date

Signature of co-applicant, if for joint account

Date