Name:
Address:

Phone (H):

E-mail Address:
Social Security Number:
Date of Birth:

Rent Own	How long at address?

Previous Address: (if less than 2 years)
Marital Status:
Number of Dependents:
Place of Employment:
Address:
Phone:
How long there?:
Monthly Income?:

Previous Employment: (if less than 2 years)
Address:
Phone:
How long there?:
Monthly Income?:

Joint Applicant:
Name:
Address:
Phone:
Joint Applicant Place of Employment:
Address:
Phone:
How long there?:
Monthly Income?:

Bank Reference:
Address:
Phone:
Type of Account:

Balance:
Credit Reference:
Name of Creditor:
Credit Limit:

Type of Product which you want to purchase:

Computer     Educational Material     Both

I want to be notified by:   Fax    E-mail    Phone