Customer Application Personal Information Last Name First Name Middle Initial Social Security Number Date of Birth Home Phone Number Cell Phone Number Physical Address City State Zip Is the mailing address the same as the physical address? Yes No / If no, please provide below: Mailing Address City State Zip Own Rent How Long? Monthly Payment $ Email: Mortgage/Landlord Phone # Address: ID Type ID Number State of Issued Make/Model of Vehicle Color Year Marriage Status Spouse’s Name: Spouse Employer: How Often Paid? Days of the Week Paid Employer Supervisors Name Address Full Time Part Time Date of Last Paycheck Days of the Week You Work Take Home Pay (Net) Source(s) of Other Income $ Employer Information Phone # Date Employed Supervisors Phone # Ext. City State Zip Position / Title How Often Paid? Date of Next Paycheck Days of the Week Paid Mon Tues Wed Thru Fri Sat Sun Time Worked Gross Pay $ Gross Other Income Per $ Bank Information Name of Bank Checking Account Number Name/Names Listed on Checking Account Is Pay Direct Deposit into this Account? Name Routing Number Yes No Date Account Opened Personal References (Starting with the Closest Relative) Address Phone Number Relationship 1 2 3 4 5 Have you thought about filing Bankruptcy in the last 90 days? Yes No Are you currently a debtor in Chapter 7 or Chapter 13 Bankruptcy proceeding? Yes No Read Statement before signing: I certify the information supplied by me on this form is true and correct. I authorize verification of the truthfulness of all information contained herein, including contact with any person or firm listed above, and fully release all parties from all liability for any damage that may result. The company reserves the right to refuse service to any person or firm listed above, and fully releases all parties from all liability for any damages that may result. The company reserves the right to refuse services to any person for any reason, including but not limited to the making of any false, misleading or incomplete statements. I have read and understand the above statements. Signature: _________________________________________________________ Date: _____________________ Read Statement before Signing: I certify that I am NOT an active duty member of the armed forces or on Guard and Reserve Duty. Nor am I a dependent of a member of the armed forces or soldier on active Guard and Reserve Duty. Signature: _________________________________________________________ Date: _____________________ Armed Forces Waiver Federal law provides important protections to active duty members of the Armed Forces and their dependents. To ensure that these protections are provided to eligible applicants, we require you to sign one of the following statements as applicable: I AM a regular or reserve member of the Army, Navy, Marine Corps, Air Force, or Coast Guard, serving on active duty under a call or order that does not specify a period of 30 days or fewer. Signature _________________________ Date _____/_____/_______ Or I AM a dependent of a member of the Armed Forces on active duty as described above, because I am the member’s spouse, the member’s child under the age of eighteen years old, or I am an individual for whom the member provided more than one-half of my financial support for 180 days immediately preceding today’s date. Signature __________________________ Date _____/_____/_______ Or I AM NOT a regular or reserve member of the Army, Navy, Marine Corps, Air Force, or Coast Guard, serving on active duty under a call or order that does not specify a period of 30 days or fewer (or a dependent of such a member). Signature __________________________ Date _____/_____/_______ Warning: It is important to fill out this form accurately. Knowingly making a false statement on a credit application is a crime.