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APPLICANT- Please Read the following before completing this form: (1) Applicant represents that the information given in this application is complete and accurate and authorizes us to check with credit reporting agencies, credit references and other sources disclosed herein in investigating the information given. (2) Married applicants may apply for an individual account. TYPE OF CREDIT APPLYING FOR:

ARE YOU CURRENTLY IN BAKRUPTCY, OR ARE YOU CONSIDERING FILING FOR BANKRUPTCY WITHIN THE NEXT SIX MONTHS?: YES (OR) NO FINANCING OPTIONS: (CHOOSE ONE) 0% INTREST FOR 12 MONTHS-$750.00 MINIMUM 24% INTREST FOR 24 MONTHS-$500.00 MINIMUM NAME/ DATE OF BIRTH: (LAST, FIRST, M.I.)
OF
/ IDENTIFICATION: LICENSE NUMBER: STATE: EXPIRATION DATE: / / SOCIAL SECURITY NUMBER: MARITAL STATUS: (CIRCLE ONE) MARRIED / UNMARRIED CONTACT INFORMATION: HOME PHONE: MOBILE PHONE: EMAIL: ADDRESS: STREET/APT: CITY/STATE/ZIP: COUNTY/PARISH: YEARS AT RESIDENCE: CURRENT RESIDENCE: (CIRCLE ONE) RENT / OWN (PAID IN FULL) / OWN (MORTGAGE) / LIVING W/ RELATIVES RENT/MORTGAGE AMOUNT: PREVIOUS ADDRESS: STREET/APT CITY/STATE/ZIP COUNTY/PARISH: YEARS AT RESIDENCE: EMPLOYMENT: EMPLOYMENT STATUS: EMPLOYED / UNEMPLOYED / RETIRED / DISABILITY/SOCIAL SECURITY CURRENT EMPLOYER: EMPLOYER: TITLE/OCCUPATION: GROSS MONTHLY INCOME: NET MONTHLY INCOME: YEARS AT EMPLOYER: PREVIOUS EMPLOYER: EMPLOYER: TITLE/OCCUPATION: GROSS MONTHLY INCOME: NET MONTHLY INCOME: YEARS AT EMPLOYER: CO-APPLICANT NAME: (LAST, FIRST, M.I.) DATE OF BIRTH / / CO-APPLICANT EMPLOYMENT: EMPLOYER: TITLE/OCCUPATION: GROSS MONTHLY INCOME: NET MONTHLY INCOME: YEARS AT EMPLOYER: CO-APPLICANT IDENTIFICATION: LICENSE NUMBER: STATE: EXPIRATION DATE: / / SOCIAL SECURITY NUMBER: MARITAL STATUS: (CIRCLE ONE) MARRIED / UNMARRIED REFERENCES: CONTACT NAME: PHONE NUMBER: RELATIONSHIP: LOAN REQUEST AMOUNT: ($500+) $ BREIF DESCRIPTION OF ITEMS YOU ARE PURCHASING: SIGNATURE: APPLICANT SIGNATURE DATE CO-APPLICANT SIGNATURE DATE
INDIVIDUAL JOINT BANKRUPTCY:
DATE
BIRTH: /

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