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First Name*

Last Name*

Email Address*

Phone #*

Street Address*

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Zip Code*

Date of Residency

This is the date you started living at your current residence

Monthly Rent/Mortgage

Social Security #*

Date of Birth*

Employment info

Employer Name*

Employer Phone #

Gross Monthly Income*

Additional Income

Date of Employment

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Total Loan Amount*

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I agree to give permission for the above applicant(s) Consumer Credit Report(s) to be obtained, at no cost to me, in order to help determine the types and extent of financing which are available*

I understand I do not have to consent as a condition of purchase or to receive any services. By checking this box, I agree Genesis, Genesis retailers and/or their vendors may use the number provided to make telemarketing calls or texts via automated technology. Carrier charges may apply.

^{By submitting your information, you agree to the sharing of your information between Genesis Motor America and its authorized retailers.}

^{In connection with your transaction, Genesis of St. Augustine may acquire information about you as described in this notice, which we handle as stated in this notice.}

^{We may collect personally identifiable information such as name, postal address, telephone number, e-mail address, social security number, date of birth, etc. This personal information is collected and used by Genesis of St. Augustine Credit Application staff for the purpose of facilitating a relationship or business transaction.}

^{Our website resides behind a firewall and uses SSL (Secure Sockets Layer, the industry-standard security protocol used to communicate with browsers) to transmit personal information. Data is strongly encrypted during transmission to ensure that personal and payment information is secure. Industry-standard data encryption techniques are used to protect personal information.}

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