PRE CREDIT INFORMATION

                                                                           [ * Required Information ]

*FIRST:                                        *MIDDLE:                                        *LAST:

*PHYSICAL ADDRESS:

*CITY:                                                          *STATE:                    ZIP:

*EMAIL ADDRESS:

*DAYTIME PHONE:                          *EVENING PHONE:                           CELL PHONE:

*DATE OF BIRTH:                           *SOC. SEC:                                                                 

*APPLICANT'S OCCUPATION:

*CURRENT EMPLOYER:

*CURRENT EMPLOYER ADDRESS:

*WORK PHONE NUMBER:                              GROSS MONTHLY INCOME:

*HOW LONG AT PRESENT EMPLOYMENT:

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For the purpose of securing credit from you, I certify that the above information is true and complete

to the best of my knowledge. I further certify that I have attained the age of maturity. I authorize you

to check my credit and employment history and to provide and/or obtain information about credit

experience with me.

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SAMS AUTOMALL

Wichita, Kansas