Customer Application and Information Request Form

Primary Applicant

First Name
Last Name
Date of Birth
Social Security Number
Phone Number
Address
City
State
Zip Code
Landlord/Mortgage Name
Payment
Employer Name
Previous Employment
Other Income Source

Vehicle you may trade
How much can you pay down?
If you have a vehicle financed now, list source
Have you ever filed bankruptcy?	YesNo
Your email address
ELECTRONIC SIGNATURE PORTION

If there is no co-signer, please scroll to the bottom of the page and click 'Submit'

Co-Signer Applicant

First Name
Last Name
Date of Birth
Social Security Number
Phone Number
Address
City
State
Zip Code
Landlord/Mortgage Name
Payment
Employer Name
Previous Employment
Other Income Source

Vehicle you may trade
How much can you pay down?
If you have a vehicle financed now, list source
Have you ever filed bankruptcy?	YesNo
Your email address
ELECTRONIC SIGNATURE PORTION

** By typing your name and clicking on 'SUBMIT' below, you acknowledge and agree to all the following:

- I agree to proceed with the credit application through electronic means;

- I agree that my electronic signature is the equivalent of a manual signature and that Whitestone Financial may rely on it as such;

- I acknowledge and agree that the individual completing this Consent to Proceed Electronically is the individual whose name the application is being requested and whose name is typed below;

- I acknowledge that Whitestone Financial believes this information to travel to us securely. However, we take no responsibility for your information from the time you submit it until the time it reaches us electronically.

- I acknowledge that Whitestone Financial may retrieve a consumer credit report and I grant them permission to do so based on my information and electronic signature.