Current Address: Street &
Social Security #:
Date of Birth (07/04/70):
Driver's License #:
Do you rent or own?:
Mthly rent/mtg: $
How long at this residence?
How long at prev. residence?
Gross Monthly Income: $
Other Income (disability, child support):
Have you ever filed for bankruptcy?
Have you ever had a car or other merchandise
Statement of Consent
I certify that the information provided
by me is correct. I also understand that you will be checking
with credit reporting agencies. I authorize an investigation of
my credit and employment history and the release of information
about my credit experience. I have read and received a copy of
your Privacy Notice and agree
to all of the above.