| Fields
marked with a *
are required |
| *
Store Name |
*
Phone or Fax |
App ID |
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| *
Last Name |
*
First Name |
Initial
|
*Date
of Birth |
Spouse
Name |
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| No.
of Dependent Children |
*
Telephone |
|
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| *
Street Address |
*
City |
*
State |
*
Zipcode |
No.
of Years |
|
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| *
Social Security No. |
*
Drivers License No. |
*
State |
*
Bank Name |
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| Own:
Rent:
|
*
Monthly Payments |
| |
|
|
$
|
|
| *
Name and Address of LandLord/Mortgage Holder
|
|
|
| Previous
Address (If less than 3 years at present address) |
No.
of Years |
|
|
|
| *
Present Employer |
|
*
Position |
*
No. of Years |
|
|
|
|
| *
Monthly Income |
Telephone |
|
|
| $
|
|
|
|
| *
Employers Address |
|
*
City |
*
State |
|
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|
| Previous
Employer (If present employment less than 3
years) |
Address |
City |
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| Other
Income |
Source |
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|
| *
Nearest Relative/Friend (Not living with you)
|
*
Relationship |
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| *
Address |
|
|
| *
City |
|
*
State |
*
Telephone |
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| *
Piano Interested In |
*
Listed Piano Price |
*
Down Payment |
|
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|
.If Co-Applicant, Please complete the following
(Applicant and Co-Applicant Must Reside at same
address) |
| Last
Name |
First
Name |
Initial |
Relationship
to Applicant |
|
|
|
|
|
| Social
Security No. |
Date
of Birth |
|
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|
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|
| Present
Employer |
Position |
No.
of Years |
Monthly
Income |
|
|
|
|
$
|
| Employers
Address |
City |
State |
Telephone |
|
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|
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|
| Credit
References |
|
|
|
|
| Name |
|
Account
# |
|
|
| 1.)
|
|
|
| 2.)
|
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|
NOTICE
TO APPLICANTS:
You may Apply for credit in your name alone
without your spouse or any other person regardless
of sex or marital status. The Federal Equal
Credit Oppourtuntiy Act prohibits creditors
from discriminating against: credit applicants
on the basis of race, color religion, national
origin sex marital status, age (provided the
applicant has the capacity to enter into a binding
contract), because all or part of the applicants
income derives from any public assistance program;
or because the applicant has, in good faith,
exercised any right under the Consumer Credit
Protection Act. The federal agency that administers
our compliance with this law is the Federal
Trade Commission, equal creditors opportunity,
Washington, DC 20580. We do state and represent
that the information listed on this applicants
is true and complete. We authorize you and/or
any proposed assigned to verify my/our credit
standing and employment as deemed neccessary.
|
| Date |
|
Witness |
|
Applicant |
|
|
|
| Date |
|
Witness |
|
Applicant |
|
|
|
| Initializing
this form acts as your signature and hereby
executes the information on the form.
|