CREDIT APPLICATION (FORM B)
Legal Name of Applicant: _______________________________________________
Present Address:
_______________________________________________________
Home Phone:
______________________ Work
Phone: _______________________
HOME DATA
Do you rent or own?
( ) rent ( )
own
How long have you lived at your present
address? __________
Previous addresses and dates you lived there:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
WORK DATA
Are you employed? _____ (If you own your own
business, go to Business Data section)
If employed, what is your present employment?
_______________________________________________________________
Name and address of employer:
_______________________________________________________________
How long have you worked for this employer?
_______________________________________________________________
If employment has been less than one (1) year, list
previous employment?
_______________________________________________________________
BUSINESS DATA
What type of business are you engaged in?
_______________________________________________________________
Name and address of business:
_______________________________________________________________
How long have you owned this business?
_______________________________________________________________
What is the legal organization of this business?
_______________________________________________________________
If business has been less than one (1) year
duration, what was your prior working/business affiliation?
_______________________________________________________________
ANNUAL INCOME
Gross income from work or business?
______________________________________
Overtime or outside income?
______________________________________
Interest and/or dividends?
______________________________________
Commissions or fees?
______________________________________
Rentals from property?
______________________________________
Other Income (specify)?
______________________________________
Total Annual Income:
______________________________________
ESTIMATED VALUE OF YOUR POSSESSIONS
Equity in home:_____________________________
Equity in other property: ______________________
Car(s):____________________________________
Savings: __________________________________
Stocks/bonds: ______________________________
Total Assets: _______________________________
ESTIMATED DEBTS
Mortgage balance: ___________________________
Car loan: __________________________________
Bank loan:_________________________________
Credit card(s): ______________________________
Other: _____________________________________
Total Debts: ____________________________
BANKRUPTCY
Have you ever found it necessary to declare
bankruptcy during the past five (5) years?
( ) yes ( ) no
What was the date? _______________
CERTIFICATION
I certify the aforegoing information to be accurate
and complete to the best of my knowledge and hereby authorize the disclosure
and release of any credit-related information based on this application to
_______________________________
______________________________________________________________.
Signed:________________________________ Date:___________________
