Please allow us to obtain a credit report on you by completing the
following information.

BORROWER NAME (first):
BORROWER NAME (middle):
BORROWER NAME (last):
SOCIAL SEC. NO. (optional):
ADDRESS1:
ADDRESS2:
CITY:
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ZIP CODE:
PHONE:
FAX:
EMAIL:
CO-BORROWER NAME (first):
CO-BORROWER NAME (middle):
CO-BORROWER NAME (last):
SOCIAL SEC. NO. (optional):
Address - same as borrower	Yes No
ADDRESS1:
ADDRESS2:
CITY:
STATE:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia                                                Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
ZIP CODE:
PHONE:
FAX:
EMAIL:

I/We authorize you to obtain a consumer credit report. Please contact me at the above phone number for further information.
ECOA NOTICE: If your application for credit is denied, you have the right to a written statement of the specific reasons for the denial. To obtain the statement, please contact us within 60 days from the date you are notified of our decision. We will send you a written statement of reasons for the denial within 30 days of receiving your request for the statement. The federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age (provided the applicant has the capacity to enter into a binding contract); because all or part of the applicant's income derives from any public assistance program; or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act. The federal agency that administers compliance with this law concerning this creditor is the Federal Trade Commission, Equal Credit Opportunity, Washington, D.C. 20580.