Retail Application

~ Applicant's Statement ~
   
Applicant Last Name
First Name
Initial
Soc. Sec. Number
Date of Birth
Co-Applicant Last Name
First Name
Initial
Soc. Sec. Number
Date of Birth
Marital Status Married Unmarried
Separated
Number of dependents
(except spouse)
Phone
Present address
Date of address (month/year)
City
state
zip
Previous Address (if less than 3 years at present)
How long?
City
state
zip
   
Housing Status Buying Renting Own
Monthly payment/rent
Current value
Balance owing
Mortgage company / landlord
Bank Acct Type Checking Savings
Bank Name / Location
Acct No.
Applicant's Present Employer
Name
Address
Phone
Position
Date Started
Salary-Gross
Salary-Net
Previous Employer (if less than 3 years at present); Address
Position
How long?
Co-applicant's Present Employer
Name
Address
Phone
Position
Date Started
Salary-Gross
Salary-Net
Previous Employer (if less than 3 years at present); Address
Position
How long?
Other Income   Month lv
Source Gross   Net
 
$
$
Assets (autos, boats, etc.)
Year Make and Model Financed by
     
     
Alimony, child support or separate maintenance income need not be revealed if purchaser does not wish to have it considered as a basis for repaying this obligation.
Nearest Relatives (not living with purchaser)
Name
Address
Phone
Relationship
Nearest Relatives (not living with purchaser)
Name
Address
Phone
Relationship
Accounts Outstanding - List all open accounts including home equity, auto, and credit union loans. List any child support or alimony if paying.
Balance Owed   Monthly Payment
Notice
The federal equal opportunity act prohibits creditors from discriminating against credit applicants on the basis of sex or marital status. The federal agency which administers compliance with this law concerning this credit application is the federal trade commission, Washington, D.C.
I/We hereby authorize you to investigate my/our credit for the above amount.
Applicant's Signature
Date:
Approved: GLA =
High Cr = Customer Cancelled
Turndown
By:
Date:
HF-0009 (Rev. 10/9/02)

Co-Applicant's Signature
Date:
Office Use Only
Reasons / Conditions