Vine – Client Financing

Personal Information

First Name(Required)

Middle Name

Last Name(Required)

Address(Required)

City(Required)

State(Required)

Zip Code(Required)

Own or Rent(Required)

Rent

Own

Parents

Other

Time At Address(Required)

*Time shown in years. If 0-11 months, select 0 yrs.

Monthly Payment(Required)

DOB(Required)

SSN(Required)

Phone Number(Required)

Email Address(Required)

Income/Employment Information

Employer Name(Required)

If you are self employed, list “self employed” as the Employer.

Occupation / Title(Required)

What is your job title or the industry you work in?

Phone Number(Required)

Length of Employment(Required)

Average Income(Required)

Income Period(Required)

How often are you paid?

Package Information

Product Description(Required)

Quantity(Required)

Please enter a number from 1 to 10.

Price Point(Required)

Term(Required)

Down Payment

CAUTION: Adding in a downpayment will reduce the overall financed package price.

First Payment Date(Required)

Ex: 04/01/2023

Payment Information (ACH)

We collect two (2) forms of payment; Credit/Debit Card & ACH.

Bank Name(Required)

Account Number(Required)

Routing Number(Required)

Account Type(Required)

Payment Information (Card)

We collect two (2) forms of payment; Credit/Debit Card & ACH.

Card Number(Required)

Card Brand(Required)

Expiration Month(Required)

Expiration Year(Required)

CVV(Required)

Two References

Please provide two references. They will be no outreach to the references provided unless the customer defaults on payments and avoids all collection efforts.

Reference #1

First Name(Required)

Last Name(Required)

Phone Number(Required)

Relationship(Required)

Reference #2

First Name(Required)

Last Name(Required)

Phone Number(Required)

Relationship(Required)