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Back to Forms for 'Consumer Credit'.




Name:  ___________________________                                Date:  ________________________


Date of Birth:  _____________________                                 SSN:  ________________________


Present Address:                                                                             Phone:  _______________________




Years At Address:  _____    Own or Rent:  ________    Monthly Payment:  _________


No. of Dependents:  _______


Name and Address of Employer:                                                   Phone:  _______________________




Years Employed:  ______________                                            Position/Title:  _________________


Gross Monthly Income:  __________                                         Gross Additional Income:  ________


Other sources of income (Specify type and amount):  ___________________________.

(Any additional income need not be revealed if the Borrower does not choose to have it considered as a basis for repaying this loan.)


If employed less than 2 years at present job, give

Name and Address of Previous Employer:                                  Phone:  _______________________

_____________________________________      Salary:  ___________________

_____________________________________      Length of Employment:  _________

Have you declared bankruptcy in the past five years?:  _____________

Are you a party to any lawsuit?:  ______________




Checking and Savings Accounts:                                                 Stocks And Bonds:

____________________________                                           _____________________________


Real Estate Owned:                                                                          Automobile Owned:

____________________________                                           _____________________________


Retirement Fund:                                                                              Net Worth of Business Owned

____________________________                                           _____________________________


Other Assets:





Credit cards:                                                                                      Notes:

____________________________                                           _____________________________


Loans:                                                                                                Other:

____________________________                                           _____________________________



____________________________                                           _____________________________

Borrower                                                                                            Date


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