Credit Application

Applicant (Required field are indicated with a red asterix.*)

* First name, initial:

* Last name:

* Street Address:

Apt. Number:

* City:

* State or Province:

* Zip or postal code:

* Home Phone:

* Date of Birth:

* Drivers Lic.

* Social Security #:

* Residence Type:

Own Rent Board

* Time At Residence:

Years     Months  

Mortgage/Rent Payment:

Mortgage Holder/Landlord:

Prev. Address #1:

Prev. Address #2:

* Email Address:

Please Tell Us About Your Income

Employer Name:

Occupation:

Work Phone:

Gross Income:

  per month

Other Income:

Time Employed:

Years     Months  

Prev. Address #1:

Phone:

Prev. Address #2:

Phone:

*Income Notice: You need not disclose alimony, child support or separate maintense
income if you do not wish to have it considered as a basis for repaying this obligation.

Co-Applicant

First name, initial:

Last name:

Street Address:

Apt. Number:

City:

State or Province:

Zip or postal code:

Home Phone:

Date of Birth:

Social Security #:

Relationship tO Applicant:

 Please Tell Us About Your Income

Employer Name:

Occupation:

Time Employed:

Years     Months  

Work Phone #:

Gross Income:

  per month

Other Income:

*Income Notice: You need not disclose alimony, child support or separate maintense income if
you do not wish to have it considered as a basis for repaying this obligation.

 Credit References

Tell us about your credit references. . .
Do you have any of the following accounts? Please check the appropriate box:

Checking:

 Yes No

Institution Name:

Savings:

 Yes No

Institution Name:

Do you have any of the following credit cards? Please check the appropriate box:

VISA	American Express	Sears
MasterCard	Discover	J.C.Penny

 Nearest relation not living with you:

* Name:

* Address:

* Phone Number:

* Relationship:

Credit Card Disclosure Chart:

ANNUAL PERCENTAGE RATE

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There is no grace period allowing you to repay your balance for purchases before being charged a FINANCE CHARGE.

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Average Daily Balance (including new purchases)

Minimum Finance Charge $.50