Fill
this form out online, then print it and initial the
bottom right corner of page 1 and sign page 2 below.
After printing and signing this form, mail or fax it to
the address at the bottom of the page.
Will you be applying for credit alone or with another person?
(Primary applicant and joint applicant must complete separate forms)
Primary Applicant
Joint Applicant
If Joint Applicant, Relationship to Primary Applicant:
Married Parent
Other
Last Name: Junior
Senior
First Name: Middle Initial:
Number of Dependents:
Applicant's Date of Birth: Month: Day:
Year: Age:
Present Address (Number and Street):
City: State: Zip:
Phone in Applicant's Home? Yes No
Phone Number: (Area Code) ()
-
Own Home Outright Buying
Home
Living With Relatives Leasing/Renting
Own/Buying Mobile Home
How long have you lived in your present location?: Years: Mos:
Name of Landlord or Mortgage Holder:
Address of Landlord or Mortgage Holder:
City: State: Zip:
Rent or Mortgage Payment: $ per
month
Previous Address (If less than 2 years at present address):
Street:
City: State: Zip:
How long did you live in your previous location? Years: Months:
Level of Education (for those applicants under age 27 only):
4 Year College Graduate 2
Year College Graduate Special Training
Some College
High School Graduate? Yes No
Current Employer Name:
Current Employer Address:
City: State: Zip:
Applicant's Occupation (if military, state rank):
How long have you worked for this employer? Years: Months:
Work Phone Number: ()
-
Gross Salary: $ Weekly
Monthly Yearly
Social Security Number: -
-
Please Initial Page 1------>_______
*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.
*Source of Other Income:
*Other Income: $ Weekly
Monthly Yearly
Previous Employer's Name (If less than 5 years at current employer):
Previous Employer's Address:
City: State: Zip:
How long did you work for this employer? Years:
Name of Bank:
Checking & Savings Checking
Only Savings Only No
Account
Have You Ever Filed Bankruptcy? No Yes
If Yes, When? Month: Year:
Is Applicant Obligated to Make Alimony, Child Support or Separate Maintenance
Payments?
No Yes
If Yes, Amount to Be Paid per Month is: $
Special Notices
- For the purpose of securing credit from you, I certify that the above information is true and complete to the best of my knowledge. I further certify that I have attained The Age of Majority.
- I authorize you to check my credit and employment history and to provide and/or obtain information about credit experiences with me.
WARNING: Falsification of your identification is fraud and will be prosecuted to the fullest extent of the law.
I acknowledge that I have read and understand the disclosures.
Signature: _________________________________ Date: __________
Sign and mail or fax to the following address:
Parkway Mobility
516 Switch Connector
Calhoun, Ga. 30701
Phone: (706)625-2131 Fax: (706)625-2189