CREDIT APPLICATION (FORM B)

 

 

Legal Name of Applicant:  _______________________________________________

Present Address:  _______________________________________________________

Home Phone:  ______________________               Work Phone:  _______________________

 

HOME DATA

Do you rent or own?  (  ) rent  (  ) own

How long have you lived at your present address?  __________

Previous addresses and dates you lived there:

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

 

WORK DATA

Are you employed? _____ (If you own your own business, go to Business Data section)

If employed, what is your present employment?

_______________________________________________________________

Name and address of employer:

_______________________________________________________________

How long have you worked for this employer?

_______________________________________________________________

If employment has been less than one (1) year, list previous employment?

_______________________________________________________________

 

BUSINESS DATA

What type of business are you engaged in? _______________________________________________________________

Name and address of business: _______________________________________________________________

How long have you owned this business? _______________________________________________________________

What is the legal organization of this business? _______________________________________________________________

If business has been less than one (1) year duration, what was your prior working/business affiliation? _______________________________________________________________

 

ANNUAL INCOME

Gross income from work or business?

______________________________________

Overtime or outside income?

______________________________________

Interest and/or dividends?

______________________________________

Commissions or fees?

______________________________________

Rentals from property?

______________________________________

Other Income (specify)?

______________________________________

Total Annual Income:

______________________________________

 

ESTIMATED VALUE OF YOUR POSSESSIONS

Equity in home:_____________________________

Equity in other property: ______________________

Car(s):____________________________________

Savings: __________________________________

Stocks/bonds: ______________________________

Total Assets: _______________________________

 

ESTIMATED DEBTS

Mortgage balance: ___________________________

Car loan: __________________________________

Bank loan:_________________________________

Credit card(s): ______________________________

Other: _____________________________________

Total Debts: ____________________________

 

BANKRUPTCY

Have you ever found it necessary to declare bankruptcy during the past five (5) years?

(  ) yes                (  ) no

What was the date? _______________

 

CERTIFICATION

I certify the aforegoing information to be accurate and complete to the best of my knowledge and hereby authorize the disclosure and release of any credit-related information based on this application to _______________________________

______________________________________________________________.

 

 

 

Signed:________________________________  Date:___________________