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 applicatin 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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