Use this form to qualify for financing pre-approval. Contact Information Name: Address: City, State, Zip: Date of Birth  MM    DD    YY Home Phone: Cell Phone: Email: Employment Information Employer: Monthly Income: Other Income Source: Monthly Income: PRIVACY NOTICE In connection with your transaction, Brenner/Leidy Car Credit may acquire information about you as described in this notice, which we handle as stated in this notice. This does not apply to information obtained in a non-financial transaction. 1. We collect non-public personal information about you from the following sources: - Information we receive from you on applications or other forms in connection with a financial transaction; - Information about your transactions with us, our affiliates or others; and, - Information we receive from a consumer reporting agency. 2. We may disclose all of the information we collect, as described above, to companies that perform marketing services or other functions on our behalf or to other financial institutions with whom we have joint marketing agreements. We may make such disclosures about you as a consumer, customer, or former customer. 3. We may also disclose non-public personal information about you as a consumer, customer, or former customer, to non-affiliated third parties as permitted by law. 4. We restrict access to non-public personal information about you to those employees who need to know that information to provide products or services to you. We maintain physical, electronic, and procedural safeguards that comply with federal regulations to guard your non-public personal information. Thank you for taking time to read this Notice.  I have read and understand the Privacy Notice. (must read and check)  I (we) assure you that the submitted information is complete and correct and has been submitted for the purpose of obtaining credit. I understand that the information will be verified and a credit report will be run in order to determine credit worthiness. I also understand that I may be required to provide additional information and stipulations which may be legally required to determine credit worthiness. I also understand that providing false information may disqualify me for credit. (must read and check) All fields are required