BEN AUTO HAUS  
Phone:(714) 636-8755 Fax:(714) 534-6868
Please fill out the following form, one of our sales representitives will get back to you within 24 hours.
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Personal Information
Email Address*   Driver Lic #* Customer Type
 
First Name* MI Last Name*
Social Security #* Number of Dependents(including self)*
Date of Birth* Home Phone* Other Phone
 
Residence
Residence Monthly Rent/Mortgage Payment* Landlord/Mortgage Holder*
Current Street Address*
City* State* Zip*
Years at Current Address*
 
Previous Address if less than 2 years at current address.
Previous Street Address
City State Zip
Years at Previous Address
 
Employment
Current Employer* Employer's Phone*
Employer's Street Address*
City* State* Zip*
Time on Current Job
Your Job Title* Gross Annual Wage*
 
Previous Employer (or school) if less than 2 years at current employer.
Previous Employer Employer's Phone
Employer's Street Address
City State Zip
Time on Previous Job
 
Additional Income
Description Annual Amount
 
Budget
Maximum Down Payment*
Maximum Monthly Affordable Payment*
 
Miscellaneous
Bank Accounts Your Initials*
Checking Savings
     
 
Have you had any of the following
Repossession Bankruptcy Garnishment
 
Comments
 
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