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Consumer Credit Application

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 (--) 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