Name (Nombre)
First Name
Last Name
Address (Dirección)
Street Address
Street Address 2
City
State
Zip Code
Contact Information (Información de contacto)
Phone Number
Email
Date of Birth
Social Security # (# de Seguro)
Driver License # (Numero de Licencia y Estado)
What location do you prefer?
Employer (Empleador)
Employer Zip (Código)
Employer City (Cuidad de Empleador)
Employer State (Estado)
Employer Phone (Extension/Numero de telefono de Empleador)
Hire Date (Fecha de contratación)
Monthly Income (Ingreso Mensual)
When are you paid? (Cuando se le paga?)
Last Payday (Ultimo dia de pago)
Next Payday (Proximo dia de pago)
Bank Name (Nombre de banco)
Routing # (Numero de ruta del banco)
Checking account # (# de cuenta de cheques)
Date Checking Account Opened (Approximately (aproximada Fecha abierta)
Credit Card # (# de tarjeta de crédito)
Credit Card Expiration (Fecha de vencimiento de tarjeta)
Cardholders full name (Titular de la tarjeta)
CVV
Billing Address (Domicilio fiscal)
Relative/Reference #1 (Reference/Relative must not live with you)
Relative/Reference #1 Address
Relative/Reference #1 Phone
Relative/Reference #2 (Reference/Relative must not live with you)
Relative/Reference #2 Address
Relative/Reference #2 Phone
Upload Image of Drivers License (Imagen de licencia para conducir)
Upload Image of Bank/Credit Card (Imagen de tarjeta de crédito)
Acknowledgment
By clicking 'SUBMIT', I acknowledge that I am signing this application electronically, and that my electronic signature is the legal equivalent of my written signature on the Application. I consent to be bound by the terms and conditions and important disclosures of the Application. I further understand that I am requesting that "Espino's Tires & Auto Center Website, its Partners or its subsidiaries" enter a payment plan agreement with me. I hereby: Certify that all information I have provided or will provide is true, correct, and complete; Consent to receive the disclosures contained in the application electronically; Consent to Espino's Tires & Auto Center Website, its Partners, or subsidiaries contacting any person or company listed on my application to obtain information about me and fully release all parties from any claim that may arise out of such contact; Authorize "Espino's Tires & Auto Center Website, its Partners, or its subsidiaries" to charge any credit or debit card (as described in the application) in the amount of my initial payment if my application is approved and I execute a payment plan agreement with "Espino's Tires & Auto Center Website, its Partners or subsidiaries" authorizing such a charge; "Agree that "Espino's Tires & Auto Center Website, its Partners, or its subsidaries" may obtain one or more consumer reports ('Consumer Reports') in connection with either (a) my application, (b) any updates, renewals, or extensions of any transaction resulting from my application ("Transactions'), (c) the review or collection of any transaction and (d) other legitimate business purposes related to any transaction; Understand that upon my request (a) I will be informed whether "Espino's Tires & Auto Center Website, its Partners, or its subsidiaries" obtained Consumer Reports, and if so, the name and address of the individual or company that furnished the Consumer Reports; Authorize "Espino's Tires & Auto Center Website, its Partners, or subsidiaries" to share information with the merchant whose goods I am interested in buying ('Dealer') about "Espino's Tires & Auto Center Website, its Partners, or its subsidiaries" decision to offer me a payment plan, and Authorize "Espino's Tires & Auto Center Website, its Partners, or its subsidiaries" to shrea my application information and lease terms with Dealer; and understand that I can withdraw my consent by closing this web session without submitting my application.
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