Bergey's Chrysler Jeep Dodge

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Contact Information

*Legal Name
*DBA
Business Organization Structure
Other Business Organization Structure
*Social Security #/Tax ID #
*Gross Profit

*Type of Business
*Years in Business
*Email
*Phone Number
Website Address
Tax Exempt Number
State-issued Organization # (not tax id#)

Date of Birth (for individuals)

Please select a calendar date that is best for you.

Address Information

Primary Legal/CEO Address

*Primary Legal/CEO Address
*City
*County
*State
*Zip Code

Billing Address

Billing Street (if different than Primary)
City
County
State
Zip Code

Extra Information

Time at Present Address
Residence Type
Monthly Rent/Mortgage Payment

Fleet/Garage Information

Garage Information

Garage Street
City
County
State
Zip Code
Phone #

Fax #
Mobile Phone #
FCONTA

FLEETI

Fleet Manager Name
Phone #
Email

Owner/Guarantor Information

Owner/Guarantor 1

*Owner/Guarantor 1 Name
*Title
*Address
*Phone
*Social Security / TN #
*Date of Birth
*Ownership %

Owner/Guarantor 2

Owner/Guarantor 2 Name
Title
Address
Phone
Social Security / TN #
Date of Birth
Ownership %

Bank Information

Bank

Bank City
BSTATE
*Telephone #
*Contact
*Account #

Trade

Trade City
LSTATE
*Telephone #
*Contact
*Account #

Important Privacy Information

Privacy Statement

Introduction

As a valued customer, we want to ensure your private information is kept private and only shared with those companies who are authorized either by yourself or as allowed or required by law.  This document explains our privacy policy, gives you reasons why we ask for the type of information we do, and if we do reserve a right to share information with non-affiliated third parties, lets you "opt-out" of our reservation to do so.  Please take a moment to read this entire policy.

Collection of Information

The purchase of a motor vehicle requires considerable accumulation of nonpublic personal information.  For example, if we sell or lease you a vehicle - extending you credit at your request - we will receive information from you in order to determine your creditworthiness.  We may also obtain information from a credit-reporting agency.  We may also obtain information from third parties such as employers, references and insurance companies.

Some of the information we obtain from you may be required by state of federal agencies, such as the Department of Motor Vehicles or the Internal Revenue Service. This information may be required even if you were to pay cash for your vehicle. Examples would be a driver's license or social security number.

Protecting Your Information

We safeguard nonpublic personal information according to established industry standards and procedures.  We maintain physical and electronic safeguards that comply with state and federal law.  We restrict access to nonpublic personal information about you to those employees and outside contractors who need to know the information to provide product or service to you.  We prohibit our employees and agents from giving information about you to anyone in a manner that would violate any applicable law or our privacy policy.

Information Sharing

Unless we have indicated our desire to share your nonpublic personal information with non-affiliated third parties (by checking the box in the section below), we share information:

A) As permitted by federal or state law.

B) For purposes of processing a sale or lease transaction as your request or authorize, such as submitting information to third party financial institutions that may be requested to take an assignment of the contract or verifying insurance coverage information.

C) When using outside service providers to help us provide you with products and services.  Before providing information to our service providers we enter into contractual agreements prohibiting them from disclosing or using the information other than for the purpose it was disclosed.

D) With "Affiliated" companies.  Companies that are affiliated with us include any company that controls us, any company we control, or any company under common control with us.

If the item to the left is checked, this dealership reserves the right to disclose nonpublic personal information to third parties, such as market research firms, direct marketing companies, finance service providers and others who may from time to time seek to provide you information on valuable products or services. If the item to the left is checked, I direct you not to share nonpublic personal information about me to non-affiliated third parties, except as provided in this Privacy Policy.

*I Authorize

(enter your initials)

*Applicant Name
*Applicant Title
*Date
I intend to apply for joint credit (applicant initial here)
Co-Applicant Name
Co-Applicant Title
Date
I intend to apply for joint credit (co-applicant initial here)
Guarantor Name
Guarantor Title
Date

** If corporate guarantor, authorized officer must sign and show corporate title. If partnership guarantor, a general partner must sign and show "partner" as Title. If individual guarantor, show "Individual" as Title.