Consumer Credit Application Form

Name ___________________________________________Date_______________

Address_____________________City___________State______Zip_____

How long at address___________________Own or Rent ____________

Employed by______________________________Position_____________

How long______________________________Salary $________________

No. dependents____________Type car owned_____________Year_____

Other sources of income:

___________________________________ $_______________________

___________________________________ $_______________________

Outstanding obligations:

___________________________________ $_______________________

___________________________________ $_______________________

___________________________________ $_______________________

___________________________________ $_______________________

Pending lawsuits_____________________________________________

Have you filed bankruptcy within last 6 years?_______________

Credit references:

Name______________________________Address_____________________

Name______________________________Address_____________________

Name______________________________Address_____________________

Bank references:

Name______________________________Address_____________________

Checking______________________Savings_________________________

Visa Card_____________________Master Card_____________________

American Express______________Other Credit Cards______________



NOTICE



When making application for credit, it is understood that

an investigation may be made whereby information is obtained

through personal interviews with your neighbors, friends, or

others with whom you are acquainted. This inquiry includes

information as to your character, general reputation,

personal characteristics, and mode of living. You have a

right to make a written request within a reasonable period of

time to receive additional, detailed information about the

nature and scope of this investigation.




________________________________

Applicant