Consumer Credit Application

Name _____________________________Date_______________

Address____________City___________State______Zip_____

How long at address_______________Own or Rent _______

Employed by____________________________Position______

How long____________________________Salary $_________

No. dependents__________Type car owned______Year_____

Other sources of income:

_________________________________ $__________________

_________________________________ $__________________

Outstanding obligations:

_________________________________ $__________________

_________________________________ $__________________

_________________________________ $__________________

_________________________________ $__________________

Pending lawsuits_____________________________________

Have you filed bankruptcy within last 6 years?_______

Credit references:

Name_____________________Address_____________________

Name_____________________Address_____________________

Name_____________________Address_____________________

Bank references:

Name_____________________Address_____________________

Checking_____________Savings_________________________

Visa Card____________Master Card_____________________

American Express_____Other Credit Cards______________

NOTICE

When making application for credit, it is understood that an investigation may be made whereby information is obtained through personal interviews with your neighbors, friends, or others with whom you are acquainted. This inquiry includes information as to your character, general reputation, personal characteristics, and mode of living. You have a right to make a written request within a reasonable period of time to receive additional, detailed information about the nature and scope of this investigation.

________________________________

Applicant

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