Financing Form Test

Name*

First Middle Last

Current Address*

Street Address Address Line 2 City State ZIP Code

Years at that Address*

Birthdate*

Social Security Number*

Home Phone

Cell Phone

Driver's License Number*

Email*

Last 4 digits of Debit Card*

Choose Applicable Answer*

Rent
Own
Other

Choose Applicable Answer*

House
Condo
Apartment
Mobile

Mortgage Holder (If you own your home)

Monthly Rent / Mortgage*

Property Value (If you own your home)

Present Balance (If you own your home)

Previous Address (If less than 3 years at current)

Street Address Address Line 2 City State ZIP Code

Employer Information

Employer*

Years There*

Hourly / Salary*

Monthly Income Gross / Net*

Employer Address*

Street Address Address Line 2 City State ZIP Code

Job Title*

Employer Phone*

Other Source of Income (Child Support / S.S.)

Amount of Other Income

References

Personal Reference*

First Last

Relation*

Reference Phone*

Financial Information

Checking / Savings Account*

Yes
No

Bank Name*

By signing below, I certify that the information provided in this form is true and correct. I understand that any information provided in this form may be used by Merchant and/or Merchant’s consumer finance lenders (including, but not limited to, Lending USA, Mariner Finance, The HelpCard, United Consumer Financial Services, and Pay Tomorrow to verify my identity, credit status, and/or employment, and I fully release all parties from any and all liability for any damage that may result. Any false statement made by me shall be sufficient basis for rejection of this application. By signing below, I authorize for a loan or line of credit from one or more lenders. I authorize lenders to obtain consumer reports and related information from one or more consumer reporting agencies, such as Equifax, and other national database.

Buyer Signature*

Date*