This document appears to be an application for individual or joint credit. It requests information about the applicant such as name, address, social security number, date of birth, employment details, income sources, bank account and reference information. There are sections for individual credit applicants as well as joint credit applicants. The document also requests details on current and previous credit obligations in order to evaluate the application.

1. Individual Credit - applying for credit in your own name and relying on your own income or assets and not the income or assets of another person as the basis for
PRINT IN repayment of the credit requested (Complete Section A)
Joint Credit - applying for joint credit with another person ( Complete Sections A and B). Relationship to joint applicant or other party, if any
BLACK
INK ONLY Individual Credit - applying for credit in your own name relying on income from alimony, child support, or separate maintenance or on the income or assets of another
person as the basis for repayment of the credit requested (Complete Sections A and B).
PRINT FIRST MIDDLE LAST SOC. SEC. NO. /TIN DATE OF BIRTH HOM E PHONE NO.
FULL
NAME
Sr
Jr.
- -
NUMBER AND STREET CITY COUNTY STATE ZIP CODE LIVED THERE
PRESENT
Years Months
ADDRESS
RENT LANDLORD OR MORTGAGE HOLDER NAME MO.. PAYMENT OR RENT
LEASE
OWN
PREVIOUS NUMBER AND STREET CITY COUNTY STATE ZIP CODE LIVED THERE
HOME
Years Months
ADDRESS
EMPLOYED BY EMPLOYER NAME BUSINESS ADDRESS, STREET & NUMBER BUSINESS PHONE CITY STATE WORKED THERE
SELF:
Years Months
OTHERS:
TRADE OR OCCUPATION SALARY OR WAGES NAME OF PREVIOUS EMPLOYER BUSINESS ADDRESS NO.YRS.
ALIMONY, CHILD SUPPORT OR SEPERATE MAINTENANCE INCOME NEED NOT BE REVEALED IF YOU DO NOT WISH TO HAVE IT CONSIDERED AS A BASIS FOR REPAYING THIS OBLIGATION.
TYPE OF OTHER INCOME SOURCE MONTHLY
AMOUNT
NAME AND ADDRESS OF PARENTS NAME ADDRESS PHONE NO. RELATIONSHI
OR NEAREST RELATIVE
NOT LIVING WITH ME
NAME AND ADDRESS NAME ADDRESS PHONE NO. KNOWN HOW LONG
OF
PERSONAL FRIEND
BANK ACCOUNT NAME OF BANK BRANCH NAME AND CITY CHECKING CHECKING ACCOUNT NUMBER
SAVINGS
NO ACCOUNT
LAST CAR NAME OF BALANCE DUE TRADING IN
FINANCED CREDITOR OR DATE PAID THIS CAR? YES NO
PRINT FIRST MIDDLE LAST SOC. SEC. NO. /TIN DATE OF BIRTH HOM E PHONE NO.
FULL
NAME
Sr
Jr.
- -
NUMBER AND STREET CITY COUNTY STATE ZIP CODE LIVED THERE
PRESENT
Years Months
ADDRESS
RENT LANDLORD OR MORTGAGE HOLDER NAME MO.. PAYMENT OR RENT
LEASE
OWN
PREVIOUS NUMBER AND STREET CITY COUNTY STATE ZIP CODE LIVED THERE
HOME
Years Months
ADDRESS
EMPLOYED BY EMPLOYER NAME BUSINESS ADDRESS, STREET & NUMBER BUSINESS PHONE CITY STATE WORKED THERE
SELF:
Years Months
OTHERS:
TRADE OR OCCUPATION SALARY OR WAGES NAME OF PREVIOUS EMPLOYER BUSINESS ADDRESS NO.YRS.
ALIMONY, CHILD SUPPORT OR SEPERATE MAINTENANCE INCOME NEED NOT BE REVEALED IF YOU DO NOT WISH TO HAVE IT CONSIDERED AS A BASIS FOR REPAYING THIS OBLIGATION.
TYPE OF OTHER INCOME SOURCE MONTHLY
AMOUNT
NAME AND ADDRESS OF PARENTS NAME ADDRESS PHONE NO. RELATIONSHI
OR NEAREST RELATIVE
NOT LIVING WITH ME
NAME AND ADDRESS NAME ADDRESS PHONE NO. KNOWN HOW LONG
OF
PERSONAL FRIEND
BANK ACCOUNT NAME OF BANK BRANCH NAME AND CITY CHECKING CHECKING ACCOUNT NUMBER
SAVINGS
NO ACCOUNT
LAST CAR NAME OF BALANCE DUE TRADING IN
FINANCED CREDITOR OR DATE PAID THIS CAR? YES NO
List all creditors and installment obligations. (Include finance companies, banks, credit cards, charge accounts. Include name(s) of applicant in which credit can be verified, if other than shown above.)
CREDITOR NAME ADDRESS
CREDITOR NAME ADDRESS
CREDITOR NAME ADDRESS
CREDITOR NAME ADDRESS
FAIR CREDIT REPORTING ACT DISCLOSURE This application for credit sale will be submitted to _________________for purchase or consideration as to whether it meets purchase requirements.
I certify that the above information is complete and accurate. I authorize an investigation of my credit and employment history and the release of information about my credit experience.
APPLICANT SIGNS: ________________________________________________________ INDIVIDUAL (CHECK WHICH APPLIES)
MONTHLY PAYMENT DATE PARTNERSHIP
DESIRED BY CUSTOMER JOINT APPLICANT OR OTHER PARTY SIGNS ----------------------------------------------------------- CORPORATION DATE: ____________