CONSUMER CREDIT APPLICATION
Last Name:
________________ First
Name: _____________ Middle Initial: ____
Social Security Number: ____-____-____
Date of Birth: _____/_____/_____
Street:
_______________________________________________________________
City:
_______________________________ State:
__________ Zip Code: ________
Telephone:
____________________________________________________________
Employer:
____________________________________________________________
Employer's Address:
____________________________________________________
Gross Salary:
____________________________________ ( Wk.___ Mo.___ Yr.___ )
Length of Employment: Years _______________ Months ________________
Position:
_____________________________________________________________
Additional Income:
_____________________________________________________
Source of Additional Income:
_____________________________________________
Number of Dependents: ______
Residence:
Own ____ Rent
____ Live with Parents ____
Mortgage Holder or Landlord:
_____________________________________________
Monthly Payment:
______________________________________________________
Have you ever declared bankruptcy or had a judgment
filed against you?
Yes
_____ No _____.
If yes, list the
Court and Date:
___________________________________________________
Checking Account #:
_______________________________________________
Savings Account #:
________________________________________________
Bank Name and Address: _______________________________________________
Credit Cards (list account number, balance and
monthly payment):
1.____________________________________________________________________
2.____________________________________________________________________
3.____________________________________________________________________
The information contained in this application is true and correct, and is
supplied to obtain credit from you. I
authorize you to verify any and every aspect of the information in the
application and any additional information that you may require in connection
with this application or in connection with any review, update, extension,
renewal or collection of any credit you extend as a result of this
application. I hereby authorize you to
report your credit experience with me to other retail establishments and credit
reporting agencies.
Applicant 1 Signature: _________________________ Date:
______________
Applicant 2 Signature: _________________________ Date:
______________