read the following directions before
completings this application and check appropriate box
If you are applying for individual credit in your
own name and are relying on your own income or assets and not the income or
assets or another person as the basis for the repayment of the credit
requested, complete only Section A
If you re applying for joint credit with
another person or are relying on the income or assets of another person as the
basis for repayment of the credit requested, complete Sections A & B,
providing information in Section B about the joint applicant or other party.
full name - last:
first:
middle:
birth date:
social security no:
personal email address:
present street address city
state zip:
# yr:
telephone no:
previous street address (if less than 3 yrs.at
present)
city:
state:
zip:
# yrs:
present employer
telephone:
address:
position or title
yrs.there:
previous employer (if less than 3 yrs. at present
job)
yrs. there:
address:
own home:
rent:
rent/mtg $:
name of nearest relative not living with you
address :
relationship:
phone no. $:
alimony, child support, or separate maintenance income need not be
revealed if you do not wish to have it considered as a basis for repaying this
obligation.
other income $ per:
source (s) of other income $ per:
make & year auto owned
financed by:
name and address:
trade:
yes
no
joint applicant or other party information - complete this
section only if box 2 at top of application is checked
full name - last:
first:
middle:
birth date:
social security no:
driver's license no:
present street address
city:
state:
zip:
# yr:
telephone no:
present employer
telephone:
address:
position or title
yrs. there:
present net salary or commissions $ per:
previous employer (if less than 3 yrs. at presnet
job)
yrs. there:
address:
own home rent
rent/mtg. $:
alimony, child support, or separate maintenance income need not be
revealed if you do not wish to have it considered as a basis for repaying this
obligation
other income:
source(s) of other income $ per:
make & year auto owned
financed by:
name and address
trade:
yes
no
i certify that i have carefully read the foregoing statement and
that the information furnished is complete, true and correct to the best of my
knowledge and belief. i authorize you to make such inquiries regarding the
information furnished herein as may be required in connection with this
application and authorize anyone to furnish it and i agree this statement shall
remain your property whether or not this credit is granted.
date | signature of applicant |
(ls) | signature of joint applicant or other party
