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Financing

Government issued, unexpired photo identification presented at time of application, to be completed by sales rep/office
Type ID# State/Province Expiration Date
Primary Applicant Driver's License
State Issued ID Card
Passport
Resident Alien Card
Military ID
Secondary Applicant Driver's License
State Issued ID Card
Passport
Resident Alien Card
Military ID
PRIMARY APPLICANT
Last Name:
First Name :
Date of Birth (mm/dd/yyyy):
Social Security Number:
Email Address :
Rent/Mortgage Paid Monthly:
Legal Resident Of The United States?
Yes
NO
Physical Address (cannot be PO Box):
 City:
State:
Zip:
Country:
Mailing Address (if different):
 City:
State:
Zip:
Country:
Three DIFFERENT Phone Numbers are required
Phone Number:
 Cell Number:
 Work Phone:
 Message Phone:
Current Employer:
 Position:
Date of Hire:
Monthly Income (proof may be required):
Other source of income and amount. Please note, alimony, child support, or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.
Amount:
Second / Additional Job
Retirement/Pention/Social Security, etc.
Rental Income
Alimony/Spousal Support
Other (please describe)
References - Please list three personal references (these three reference phone numbers should be different from the above three numbers)
Name Phone Number Relationship to you












SECONDARY APPLICANT We intend to apply for joint credit:
Primary applicant initials:		 Secondary applicant initials:
Last Name:
First Name :
Date of Birth (mm/dd/yyyy):
Social Security Number:
Email Address :
Rent/Mortgage Paid Monthly:
Legal Resident Of The United States?
Yes
NO
Physical Address (cannot be PO Box):
 City:
State:
Zip:
Country:
Mailing Address (if different):
 City:
State:
Zip:
Country:
Three DIFFERENT Phone Numbers are required
Phone Number:
 Cell Number:
 Work Phone:
 Message Phone:
Current Employer:
 Position:
Date of Hire:
Monthly Income (proof may be required):
Other source of income and amount. Please note, alimony, child support, or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.
Amount:





Please read before signing

To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. What this means for you: When you open an account, we will ask for your name, address, date of birth and other information that will allow us to identify you. We may also ask to see your driver’s license or other identifying documents.

You hereby acknowledge that you are over the age of eighteen (18) years, and that all of the information set forth in the credit statement is true, accurate and full and complete disclosure thereof. You are providing written consent under the Fair Credit Reporting Act for us and our affiliates, agents, successors, assigns and service providers with whom you are matched to obtain a consumer credit report from a contracted credit bureau. You understand that you are submitting an application for credit, and are consenting to the use of your credit report information. You authorize the holder of this application to verify all data contained in said application, using validation services thru third party vendors. If this application results in a Retail Installment Contract or Closed End Consumer Lease, you authorize any holder of the Retail Installment Contract or Closed End Consumer Lease or any person, firm or corporation requested to extend credit there under, (including any employee or agent of any of them) to communicate with your employer in order to verify your employment.

You authorize any holder of the Retail Installation Contract or Closed End Consumer Lease, the creditor thereof, or any Attorney, debt collector or collection agency to communicating any and all information concerning this application or debt to any credit reporting agency or other creditor. By providing your email address, you consent to receive electronic information such as monthly billing reminders, statements and collection notices. You also acknowledge that we and our partners may use all contact information provided to contact you regarding your application, Retail Installment Contract or Closed End Consumer Lease, account status or future issues. You expressly consent and agree that we and our affiliates, agents, successors, assigns and service providers may use written, electronic and verbal means to contact you. This consent includes, but is not limited to, contact by manual calling methods, prerecorded or artificial voice messages, text messages, emails and/or automatic telephone dialing systems. You agree that we and our affiliates, agents, successors, assigns and service providers may use any email address or telephone number you provide, now or in the future, including a number for a cellular phone or other wireless device, regardless of whether you incur charges as a result. You further acknowledge and agree, that you will notify the us and our affiliates, agents, successors, assigns and service providers in writing of any change in your name, address or employment within a responsible time thereafter. You agree that any and all acknowledgements provided by you in the Contract are provided to us in further consideration of the extension of credit to you and are essential terms of the Contract.

NOTICE TO CALIFORNIA CUSTOMERS: A married applicant may apply for a separate account.

NOTICE TO OHIO CUSTOMERS: The Ohio laws against discrimination require that all creditors make credit equally available to all creditworthy customers, and that credit reporting agencies maintain separate credit histories on each individual upon request. The Ohio civil rights commission administers compliance with this law.

NOTICE TO NEW YORK CUSTOMERS: In connection with your application for credit, a consumer report may be obtained which contains information on your credit worthiness, credit standing, credit capacity and general reputation. If you request, you will be informed whether a consumer report was obtained and if so, you will be given the name and address of the consumer reporting agency which furnished the report. If your application is granted, subsequent consumer reports may be obtained in connection with any update, extension or renewal of credit.

NOTICE TO RHODE ISLAND CUSTOMERS: Consumer reports may be requested in connection with this application.

NOTICE TO VERMONT CUSTOMERS: If an account is created, I authorize the obtaining of credit reports for purposes of reviewing or taking collection action on the account or for other legitimate purposes associated with the account.

NOTICE TO WISCONSIN CUSTOMERS: The interest of the creditor will not be adversely affected by a provision of a marital property agreement, a unilateral statement under Wisconsin Statutes §766.59 or a court decree under Wisconsin Statutes §766.70, unless you furnish a copy of such agreement, statement or decree to the creditor, or the creditor has actual knowledge of such provision before credit is granted.

Applicant Signature:
 Date (mm/dd/yyyy):
Secondary Applicant Signature:
 Date (mm/dd/yyyy):


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