CONFIDENTIAL CREDIT APPLICATION

SECTION 1: APPLICANT

Have you ever filed for Bankruptcy or are you currently involved in a Bankruptcy?
Never Filed Chapter 7 Chapter 13

Last Name First Name Middle Initial

Birth Date (mm/dd/yy) Social Security Number

Email Address:

WHERE DO YOU LIVE?

CURRENT ADDRESS:

Length at address: Yrs Mos
*If you've lived at your address for less than 2 years, please give your previous address info:*
PREVIOUS ADDRESS:
	Length at address: Yrs Mos

Home Phone (area) xxx-xxxx Cell Phone (area) xxx-xxxx

WHO DO YOU WORK FOR?	Current Employer
Employer Name
Position/Title
Contact Name
Contact Phone
Years/Months with Employer	Yrs Mos
Gross (pre-tax) Income/month

Other Income
Source 1
Amount

*If you've been on your job for less than 2 years, please give your previous employment information:*	PREVIOUS Employer
Employer Name
Position/Title
Contact Phone
Years/Months with Employer	Yrs Mos

SECTION 2: CO-APPLICANT

Last Name First Name Middle Initial

Birth Date (mm/dd/yy) Social Security Number

Please provide your addresses for the past 3 years:

Current Address:

Length at address:
Yrs Mos

Home Phone Cell Phone

CO-APPLICANT	Current Employer
Employer Name
Position/Title
Contact Name
Contact Phone
Years/Months with Employer	Yrs Mos
Gross (pre-tax) Income/month

Other Income
Source 1
Amount

SECTION 3: ASSET & DEBT INFORMATION

Type of Residence:
Homeower Renting Living with relatives

Landlord or Mortgage holder
Landlord or Mortgage holder phone number (area) xxx-xxxx

Rent/Mortgage Payment $ 2nd Mortgage Payment $

Your Bank Name
Have checking account
Have savings account
Have checking AND savings account

SECTION 4: BANKRUPTCY

If you are in the middle of a Bankruptcy; is this your first bankruptcy?
Yes No

When is/was your 341 meeting?

What caused your bankruptcy?

If bankruptcy is filed jointly, can joint borrower sign with you?
Yes No Filed individually

For those items that you did reaffirm (keep), please provide the following information about them:

	With Who?	Payment Amount	Current?
Mortgage 1			Yes No
Mortgage 2			Yes No
Car Loan 1			Yes No
Car Loan 2			Yes No
Furniture Loan			Yes No
Student Loan			Yes No
Other Loan			Yes No

Are you currently obligated to pay any of the following?

Child Support: $

Child support deducted from payroll?
Yes
No

Alimony $

Alimony deducted from payroll?
Yes
No

Other Garnishments $

Is your current mortgage or lease (rent) up to date?
Yes No

SUBMIT YOUR APPLICATION

I certify that the above information is true and accurate to the best of my knowledge. I hereby authorize the investigation of my credit, employment and residency history and authorize the release of information about my credit situation.