Loan Applicant: (Please fill in all requested data.)   Individual:

First Name:    Middle Name:    Last Name:   

Address 1:    Suffix: None Sr. Jr III IV V

Address 2:  

City:      State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming    Zip code:      

Drivers License #:    Drivers License State:  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming   Expires:

SS Number:           Date of Birth:     E-Mail:  

Home Phone:     Work Phone:     Cell Phone:

Own/Rent: Own Rent    Mortgage/Rent Payment:     Time @ Current Address: (Months)  (Years)

Mortgage Holder/Landlord Name:   Phone:

(Required If less than 2 years at current address)

Previous Address:    

City:     State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming    Zip code:

Time @ Previous Address: (Months)  (Years)

Employment:  (Please fill in all requested data.)    Self Employed:     

Employer:   Title Position:    Years Employed:

Address:   

Supervisor:    Phone:     Gross Monthly Wages:

City:          State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming      Zip Code:

Other Income:        Other Income Source*:   

  *Alimony, child support or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.

  Have you declared bankruptcy in the last 10 years?   Yes No    

  Have you ever had property repossessed? Yes No

  Have you ever had any Judgments or Garnishments filed against you? Yes No

Bike Details: (Please tell us about the bike you are interested in)

Manufacture: American IronHorse Big Dog Motorcycles Wild West Motorcycles Harley Davidson Other    Year:   Make:  

Model:     New / Used:  New Motorcycle Used Motorcycle Demo Motorcycle Other          

Sale Price:    Cash Down Payment:   Invoice Amount:

By Pressing the Submit button above: The Applicant/Co-applicant HEREBY:

1. Understand and agree that Empire Cycles or any of its credit lending agencies may make credit and employment inquiries about me, may provide and exchange information about me with any source of credit information to which the bank may inquire, and may disclose information about me with other financial institutions for the purposes of fulfilling this credit request.

2. Certify that all information provided on this application or in connection with this application is true, correct and complete, even if completed by an agent. Understand the bank will rely on the information in this credit application in making its decision and also understand that making false statements in order to obtain credit may be a crime.

3. Certify that I am a U.S. Resident.

4. Agree that if credit is approved, the bank may obtain subsequent consumer reports in connection with reviewing the account, and taking collection action on the account, or for other legitimate purposes associated with the account.

5. Provide express written consent for you to contact me/us, in connection with my/our loan, at the contact phone number(s) and e-mail address(s) provided.

Notices :

New York Applicants: In connection with your application for credit, we may request a consumer report which contains information on your credit worthiness, credit standing, personal characteristics and general reputation. If we grant you credit, We (or our loan servicer) may order additional consumer reports in connection with any update. renewal or extension of the credit. If you ask us, we will tell you whether we obtained a consumer report and, if we did, we will tell you the name and address of the consumer reporting agency that gave us the report.