Subscription Application - Step 1 of 4Name *FirstLastDriver License *Date of Birth *Home PhoneMobile Phone *Email *NextAddress *Address Line 1Address Line 2CityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHousing Status *RentOwnLive w/ relativesTime at Adrress *FirstLastMtg Pmt or Rent *NextType of Income *W2Self Employed / 1099Retired / Fixed IncomeEmployer Name *Phone *Time Employed *FirstLastOccupationMonthly Salary (Gross) *NextPrimary Driver License Upload *MUST BE VALID AND UNEXPIRED. IF NOT A U.S. ISSUED LICENSE ADDITIONAL DOCUMENTATION MAY APPLY.Secondary Driver License UploadMUST BE VALID AND UNEXPIRED. IF NOT A U.S. ISSUED LICENSE ADDITIONAL DOCUMENTATION MAY APPLY. Proof of Income UploadMOST RECENT PAY STUB – LESS THAN 30 DAYS OLD – OTHERWISE LAST TWO MONTH’S BANK STATEMENTS IF SELF-EMPLOYED. Proof of Residence UploadUTILITY BILL – NO LESS THAN 30 DAYS OLD OR PHONE BILL – NO LESS THAN 30 DAYS OLD OR TWO OTHER NON-UTILITY BILLS IN SUBSCRIBER’S NAME AT HOME RESIDENCE. Insurance UploadDECLARATIONS OR ID CARD PAGE SHOWING THE ADDED VEHICLE AND COVERAGES.CERTIFICATION AND AUTHORIZATION *By applying, you are certifying that you understand the services being requested are regulated by the Fair Credit Reporting Act. Any special procedures established by AmeriDrive or its affiliates, for obtaining your authorization to receive information from a consumer reporting agency have been met. We may conduct an eligibility inquiry (known as a “soft credit pull”). This inquiry does not affect your credit score. Furthermore, you certify that you have initiated a transaction with AmeriDrive, and that the services being requested may be used to confirm your identity to avoid fraudulent transactions in your name. You have the right under the Fair Credit Reporting Act to receive one free credit report from each of the three U.S. national credit reporting agencies (Experian, Equifax, and TransUnion) during any 12-month period. You may also be able to receive free credit reports as permitted by state law (you may contact your state or local consumer protection agency or state attorney general to learn more about your rights).SignatureClear SignaturePhoneSubmit
