SCUSA Dealer Principal Identification Form 072511
DEALER PRINCIPAL IDENTIFICATION FORM LIST THE NAMES OF ALL EXECUTIVE OFFICERS, PRINCIPAL SHAREHOLDERS, PARTNERS, MEMBERS, AND / OR DIRECTORS, WHO OWN (10% OR MORE), CONTROL, OR HAVE THE POWER TO EXERCISE A CONTROLLING INFLUENCE OVER THE MANAGEMENT OR POLICIES OF THIS DEALERSHIP. Please note: This information is needed to comply with Santander Consumer USA AML Policies.
DEALER Dealer INFORMATION Information: _________________________________________ dealership name Dealer Name _________________________________________ physical address Physical Address _________________________________________ city, state andCity, zip State & Zip _________________________________________ dealership phone Dealership Phone _________________________________________ other phone Other Phone
PERSONPerson #1 #1: name
_________________________________________ Name
title
_________________________________________ Title
_________________________________________ home addressHome Address _________________________________________ City, State & Zip city, state and zip _________________________________________ DOB date of birth
#2 Person PERSON #2: _________________________________________ Name name _________________________________________ Title title
_________________________________________ Home Address home address _________________________________________ City, State & Zip city, state and zip _________________________________________ DOB date of birth
Person #3:
Person #4:
Name
_________________________________________ Name
name
_________________________________________ Title
_________________________________________ name Title
title
_________________________________________ Home Address
_________________________________________ title Home Address
_________________________________________ home addressCity, State & Zip
_________________________________________ home address City, State & Zip
_________________________________________ city, state andDOB zip
_________________________________________ city, state and zip DOB
PERSON_________________________________________ #3
date of birth
PERSON #4
date of birth
Person #5:
Person #6:
_________________________________________
_________________________________________ Name PERSON #6
PERSONName #5
_________________________________________ Title
_________________________________________ Title
name
_________________________________________ Home Address
_________________________________________ name Home Address
title
_________________________________________ City, State & Zip
_________________________________________ title City, State & Zip
home address_________________________________________ DOB
_________________________________________ home address DOB
city, state and zip
city, state and zip
date of birth
date of birth
PAGE
© 2011 SANTANDER CONSUMER USA INC.
All Rights Reserved. // Confidential and Proprietary // Version 1.11 (072611)
7 OF 9
DEALER Dealer INFORMATION Information: _________________________________________ dealership name Dealer Name _________________________________________ physical address Physical Address _________________________________________ city, state andCity, zip State & Zip _________________________________________ dealership phone Dealership Phone _________________________________________ other phone Other Phone
PERSONPerson #1 #1: name
_________________________________________ Name
title
_________________________________________ Title
_________________________________________ home addressHome Address _________________________________________ City, State & Zip city, state and zip _________________________________________ DOB date of birth
#2 Person PERSON #2: _________________________________________ Name name _________________________________________ Title title
_________________________________________ Home Address home address _________________________________________ City, State & Zip city, state and zip _________________________________________ DOB date of birth
Person #3:
Person #4:
Name
_________________________________________ Name
name
_________________________________________ Title
_________________________________________ name Title
title
_________________________________________ Home Address
_________________________________________ title Home Address
_________________________________________ home addressCity, State & Zip
_________________________________________ home address City, State & Zip
_________________________________________ city, state andDOB zip
_________________________________________ city, state and zip DOB
PERSON_________________________________________ #3
date of birth
PERSON #4
date of birth
Person #5:
Person #6:
_________________________________________
_________________________________________ Name PERSON #6
PERSONName #5
_________________________________________ Title
_________________________________________ Title
name
_________________________________________ Home Address
_________________________________________ name Home Address
title
_________________________________________ City, State & Zip
_________________________________________ title City, State & Zip
home address_________________________________________ DOB
_________________________________________ home address DOB
city, state and zip
city, state and zip
date of birth
date of birth
PAGE
© 2011 SANTANDER CONSUMER USA INC.
All Rights Reserved. // Confidential and Proprietary // Version 1.11 (072611)
7 OF 9
