APPLICANT- Please Read the following before completing this form: (1) Applicant represents that the information given in this application is complete and accurate and authorizes us to check with credit reporting agencies, credit references and other sources disclosed herein in investigating the information given. (2) Married applicants may apply for an individual account.
INDIVIDUAL
TYPE OF CREDIT APPLYING FOR: BANKRUPTCY:
ARE YOU CURRENTLY IN BAKRUPTCY, OR ARE YOU CONSIDERING FILING FOR BANKRUPTCY WITHIN THE NEXT SIX MONTHS?:
FINANCING OPTIONS:
JOINT
YES
(OR)
0% INTREST FOR 12 MONTHS-$750.00 MINIMUM
NO 24% INTREST FOR 24 MONTHS-$500.00 MINIMUM
(CHOOSE ONE)
NAME/
(LAST, FIRST, M.I.)
DATE OF BIRTH:
/
DATE OF BIRTH: IDENTIFICATION:
CONTACT
STATE:
LICENSE NUMBER:
HOME PHONE:
EXPIRATION DATE:
/
SOCIAL SECURITY NUMBER:
/
MARRIED
MOBILE PHONE:
/
MARITAL STATUS: (CIRCLE ONE)
/
UNMARRIED
EMAIL:
INFORMATION: ADDRESS:
STREET/APT:
CURRENT
(CIRCLE ONE)
CITY/STATE/ZIP:
COUNTY/PARISH:
RESIDENCE:
RENT / OWN (PAID IN FULL) / OWN (MORTGAGE) / LIVING W/ RELATIVES
PREVIOUS
STREET/APT
CITY/STATE/ZIP
YEARS AT RESIDENCE:
RENT/MORTGAGE AMOUNT:
COUNTY/PARISH:
YEARS AT RESIDENCE:
ADDRESS: EMPLOYMENT:
EMPLOYMENT STATUS:
CURRENT
EMPLOYER:
TITLE/OCCUPATION:
GROSS MONTHLY INCOME:
NET MONTHLY INCOME:
YEARS AT EMPLOYER:
EMPLOYER:
TITLE/OCCUPATION:
GROSS MONTHLY INCOME:
NET MONTHLY INCOME:
YEARS AT EMPLOYER:
EMPLOYED
/
UNEMPLOYED
/
RETIRED /
DISABILITY/SOCIAL SECURITY
EMPLOYER: PREVIOUS EMPLOYER: CO-APPLICANT
(LAST, FIRST, M.I.)
DATE OF BIRTH
/
NAME: CO-APPLICANT
EMPLOYER:
TITLE/OCCUPATION:
LICENSE NUMBER:
STATE:
GROSS MONTHLY INCOME:
NET MONTHLY INCOME:
/
YEARS AT EMPLOYER:
EMPLOYMENT: CO-APPLICANT IDENTIFICATION: REFERENCES:
/
/
CONTACT NAME:
LOAN REQUEST AMOUNT: ($500+)
SIGNATURE:
EXPIRATION DATE:
SOCIAL SECURITY NUMBER:
MARITAL STATUS: (CIRCLE ONE)
MARRIED PHONE NUMBER:
$
APPLICANT SIGNATURE
/
UNMARRIED
RELATIONSHIP:
BREIF DESCRIPTION OF ITEMS YOU ARE PURCHASING: DATE
CO-APPLICANT SIGNATURE
DATE