Federal Auctioneers | Affordable Cars

GENERAL INFORMATION
Car Make	*
Model	*
Year	*
Mileage	*
VIN#	*
Vehicle Usage	*
Miles per year you put on car	*
Do you currently have insurance?
Policy Expiration Date
Annual or Six Month Premium
Insurance Company Name
Years with above Insurance Company	Years:
Driver License #	*
Years Licensed	Years:
First Name	*
Last Name	*
Email	*
Social Security #	*
Birth Date	* Example :06/12/1975
Address	*
City	*
State	*
Zip Code	*
Home Phone Number	* Example: 718-111-2222
Time at Residence	Years: Months: *
Type of Residence
Rent/ Mortgage

IF YOU ARE MARRIED, FILL UP SPOUSE INFORMATION
Spouse Driver License #
Spouse Years Licensed	Years:
Spouse First Name
Spouse Last Name
Spouse Social Security #
Spouse Birth Date

EMPLOYMENT INFORMATION
Employer / Company Name	*
Occupation	*
Address	*
City	*
State	*
Zip Code	*
Work Phone Number	* Example: 718-111-2222
Years Employeed	Years: Months:*
Additional Comments - Also, provide your cell phone (if any) and best time to be reached.

AGREEMENT & CONSENT
I certify that the above information is complete and accurate to the best of my knowledge. Insurance companies receiving this application will retain the application whether or not it is approved. If this application is approved, I authorize the insurance company to give credit information about me to its affiliates

Take a moment to verify the above information
Check off this box after you review the information you have supplied and agree it is accurate