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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