CREDIT APPLICATION FORM

Please fill out the application below. You may apply for credit in your name alone, whether or not you are married. If you are applying for individual credit in your name and relying on your own income or assets and not the income or assets of another person as the basis for repayment of the credit requested, complete only Section A.

If you are married and live in a community property state, please complete Section A about yourself and Section B about your spouse.

SECTION A

PERSONAL INFORMATION

Please indicate whether you are applying for:
 Individual Credit Joint Credit Community Property State Business Application

First Name

Last Name

Social Security Number

Birthdate

Address

City

State

Zip

Phone Number

Cell Number

Email

Driver's License Number

Driver's License State

RESIDENTIAL STATUS

 Homeowner Rent Family Other

Time at Address (years/months)

Rent/Mortgage Payment

Previous Address (if less than two years)

Previous City

Previous State

Previous Zip

Time at Previous Address (years/months)

EMPLOYMENT INFORMATION

Employment Type:  Employed Unemployed Self-employed Military Retired Student Other

Employer Name

Salary

Salary Type:  Weekly Bi-Weekly Monthly Annually

Occupation

Length of Employment (years/months)

Work Phone Number

Previous Employment Type:  Employed Unemployed Self-employed Military Retired Student Other

Previous Employer Name

Previous Occupation

Previous Length of Employment (years/months)

Previous Work Phone Number

Alimony, child support, or separate maintenance income need not be revealed if you do not choose to have it considered as a bases for repaying this obligation.

Other Income (monthly)

Source of Income


SECTION B

CO-APPLICANT PERSONAL INFORMATION

First Name

Last Name

Social Security Number

Birthdate

Relationship

Address (if different than main applicant)

City

State

Zip

Phone Number

Cell Number

Email

Driver's License Number

Driver's License State

Previous Address (if less than two years)

Previous City

Previous State

Previous Zip

Time at Previous Address (years/months)

CO APPLICANT EMPLOYMENT INFORMATION

Employment Type:  Employed Unemployed Self-employed Military Retired Student Other

Employer Name

Salary

Salary Type:  Weekly Bi-Weekly Monthly Annually

Occupation

Length of Employment (years/months)

Work Phone Number

Previous Employment Type:  Employed Unemployed Self-employed Military Retired Student Other

Previous Employer Name

Previous Occupation

Previous Length of Employment (years/months)

Previous Work Phone Number

Alimony, child support, or separate maintenance income need not be revealed if you do not choose to have it considered as a bases for repaying this obligation.

Other Income (monthly)

Source of Income

Comments

I certify that I have read and agree to the terms and disclosures on this application.

You agree that if an account is created for you, all of the following also apply: (a) we may monitor and record telephone calls regarding your account to assure the quality of our service or for other reasons; (b) you expressly consent to us using prerecorded/artificial voice messages, text messages and/or automatic dialing equipment while servicing or collecting your account, as the law allows; (c) you agree that we may take these actions using the telephone number(s) that you provide us in this credit application, you provide to us in the furute, or we get from another source, even if the number is for a mobile or cellular telephone and/or our using the number results in charges to you.