Automobile Note DELMarVA Judgment Services

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Automobile Portfolio Note Worksheet
*Bold fields are required*
*Name:*
Title:
Dealership:
Company:
*Address:*
*City:*
*State:*
*Zip:*
*Work#:*
Fax#:
Cell#:
Home#:
*Best time to call:*
*How did you hear of us?:*

*Email:*
*Is this a portfolio of notes?:*
*If yes, how many notes are there?:*
*Notes Balance :$*
*Interest Rate:%*
*Date of Purchase:*
*What is the Down Payment?:*
*Payment Amount:$*
*Payments Made:*
*Number of Payments Already Made:*
*Number of Payments Remaining:*
*Payment Status:*
*Payor's Credit:*
*Dealer Recourse?:*
*Why do you want to sell?*
*How much immediate cash do you need:*
*Comments:*	Enter your comments here!
The data, which we collect from you is not an application for credit. The intent of this form is for us to determine if a relationship between DELMarVA Judgment Services and/or its assigns and you and/or your company would be mutually beneficial. By submitting the required form, you authorize DELMarVA Judgment Services and/or its assigns to access any credit reporting agencies for which we are a member in your security interest under any agreements and transactions relating to DELMarVA Judgment Services and you and/or your firm. Your information is held in the strictest confidence and is used to help you achieve your goals in an expeditious and professional manner. ______________________________________________