If you are applying for individual 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 repayment of the credit requested, complete only Section A and D. If the requested credit is to be secured, also complete the first part of Section C and Section E.
If you are applying for joint credit with another person, complete all Sections except E, providing information in Section B about the joint applicant. If the requested credit is to be secured, then complete Section E.
If you are applying for individual credit, but are relying on income from alimony, child support, or separate maintenance or on the income or assets of another person as the basis for repayment on the credit requested, complete all Sections except Section E to the best possible, providing information in Section B about the person on whose alimony, support, or maintenance payments or income or assets you are relying. If the requested credit is to be secured, then complete Section E.
Amount Requested
Payment Date Desired
Proceeds of Credit to be Used for
Section A - Information Regarding Applicant
Full Name:
Birthdate:
Birth Year:
Social Security No.:
Drivers License No.:
Present Street Address:
Years There:
City:
State:
Zip:
Telephone:
Previous Street Address:
Years There:
City:
State:
Zip:
Present Employer:
Years There:
Telephone:
Position or Title:
Name of Supervisor:
Employers' Address:
Previous Employer:
Years There:
Previous Employers' Address:
Present Net Salary or Commission:
per
No. Dependents:
Ages:
Alimony, child support, or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.
Alimony, child support, separate maintenance received under:
Court Order
Written Agreement
Oral Understanding
Section B - Information Regarding Joint Applicant or Other Party
Full Name:
Birthdate:
Birth Year:
Social Security No.:
Drivers License No.:
Relationship to Applicant (if any):
Present Street Address:
Years There:
City:
State:
Zip:
Telephone:
Present Employer:
Years There:
Telephone:
Position or Title:
Name of Supervisor:
Employers' Address:
Previous Employer:
Years There:
Previous Employers' Address:
Present Net Salary or Commission:
per
No. Dependents:
Ages:
Alimony, child support, or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.
Alimony, child support, separate maintenance received under:
Court Order
Written Agreement
Oral Understanding
Section C - Marital Status
(Do not complete if this is an application for individual unsecured credit.)
Applicant:
Married
Separated
Unmarried (including single, divorced, and widowed)
Section D - Asset and Debt Information:
(If Section B has been completed, this Section should be completed giving information about both the Applicant and Joint Applicant or Other Person. Please Mark Applicant-related information with an "A". If Section B was not completed only give information about the Applicant in this Section.)
Assets Owned
Outstanding Debts (Include charge accounts, installment contracts, credit cards, rent, mortgages, etc.)
Credit References:
Amount:
Date Paid:
Credit References:
Amount:
Date Paid:
Credit References:
Amount:
Date Paid:
Are you a co-maker, endorser, or guarantor on any loan or contract?
If "Yes" for Whom?
to Whom?
Are there any unsatisfied judgments against you?
Amount
If "Yes" to Whom Owed?
Have you been declared bankrupt in the last 14 years?
If "Yes" Where?
Year
Other Obligations:
Section E - Secured Credit:
(Complete only if credit is to be secured.)
Briefly describe the property to be given as security:
List Names and Addresses of all Co-Owners of the Property:
Name:
Address:
Name:
Address:
Name:
Address:
If the security is real estate, give the full name of your spouse (if any):
Everything that I have stated in this application is correct to the best of my knowledge. I understand that you will retain this application whether or not it is approved. You are authorized to check my credit and employment history and to answer questions about your credit experience with me.
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