Email

Home Address

Street Address, Apt. No, Town, Zip Code

City, State and Zip Code

Years at this address

Date of Birth and Social Security Number

ABOUT YOUR WORK

Your Employer

Name of Company, Address, Phone No.

Annual Salary

Other Income

How long have you worked for your current employer?

Other Information You May Want Us to Consider

Complete only if your spouse will use this account or sign the agreement or if you wish the income and/or credit worthiness of your spouse considered.

Spouse

Name

Spouse's Employer

Company Name/Address/Phone. Spouses position at the company.

Spouse's Income

Annual Salary/ Other Income

Spouse's Date of Birth and Socal Security #

Spouses Phone Number (home/cell #):

Please Tell Us Your Preference

Please Tell Us Your Preference:

NOTICE TO BUYER(S):

1. PLEASE DO NOT SIGN BEFORE YOU READ THE AGREEMENT. (Please click on AGREEMENT button above to Read Agreement in Full)) 2. YOU ARE ENTITLED TO A COPY OF THE AGREEMENT AND THE INFORMATION REGARDING YOUR RIGHTS TO DISPUTE BILLING ERRORS IF YOU REQUEST SAME. 3. YOU AGREE THAT A FINANCE CHARGE OF 1.5% PER MONTH WILL BE CHARGED TO ACCOUNTS AFTER 30 DAYS.

Buyer's Signature/Date (Please type your full name and date)

NOTICE: By signing below (or entering my "signature" via the website electronically, I hereby agree to all the Terms & Conditions as indicated in the "Agreement". Additionally, I hereby authorize you or any credit reporting agency employed by you to investigate the references herein listed or any of the other information stated above to determin my qualifications for a credit account.

Spouse/Significant Other Signature/Date (Please type your full name and date)

NOTICE: By signing below (or entering my "signature" via the website electronically, I hereby agree to all the Terms & Conditions as indicated in the "Agreement". Additionally, I hereby authorize you or any credit reporting agency employed by you to investigate the references herein listed or any of the other information stated above to determin my qualifications for a credit account.