CONTENTS   Home Inventory Specials Credit Application Directions Warranty Links Contact Us       CONTACT Foley's Auto Sales 4500 LAFAYETTE BLVD FREDERICKSBURG, VA (540)898-1100 Send Us E-mail Computer Medics of Northern Virginia®2004 www.computermedicsofnova.com info@computermedicsofnova.com

PERSONAL INFORMATION Full Name Drivers License # Social Security# Present Address City State, Zip Phone Number Previous Address City State, Zip Cell Number Own Home? YesNo Pay Rent/Mortgage to Payment Amount Insurance Company Policy Number DOB dd/mm/yy Credit Cards VISAMasterCard DiscoverAm Ex E-Mail Address Employer and Credit Information Employer Emp. Address Emp. City, State Position Years Employed Work Phone Gross Weekly Income Bank Accounts Checking Savings Bank Name Other Income Desired Payment Down Payment Saved I have read the Customer Choice Notice below and understand it thoroughly. I warrant all the information submitted in this application is true and correct and have been made in order to induce you to grant me credit. You are authorized to verify these statements and obtain other information needed to appraise this application. No agreements are final until Contract is completed.