Bargain Spot Center

Last Name	First Name	Middle Initial	Social Security Number	Date of Birth

Address: Street	City	Zip	Time at Residence

	Home Phone	Cell Phone	Email

Rent:		Own:		Mortgage Holder / Landlord	Phone:	Mortgage / Rent ($)	Age of Dependents
Other

Previous Address: Street	City	Zip	Time at Residence (Yrs & Months)	Time in Area (Yrs & Months)

EMPLOYMENT / BUSINESS

Current Employer:	Address:	Phone:	Years Employed: Yr. Mo.

Self Employed:		Position	Supervisor	Phone:	Gross Monthly Income:
Other:

Previous Employer Name & Full Address:	Position	Employed Yr. Mo.	Phone:

Source of Other Income (Explain):	Amount	Per (Week, Mo)	Total Gross Monthly Income:

Marital Status:
Check one

Married:

Separated:

Unmarried (including:single, divorced and widowed).

CO-APPLICANT

Last Name	First Name	Middle Initial	Social Security Number	Date of Birth

Address: Street	City	Zip	Home Phone	Relationship to Buyer

Current Employer:	Address:	Phone:	Years Employed: Yr. Mo.

Self Employed:		Position	Supervisor	Phone:	Gross Monthly Income:
Other:

Previous Employer Name & Full Address:	Position	Employed Yr. Mo.	Phone:

Source of Other Income (Explain):	Amount	Per (Week, Mo)	Total Gross Monthly Income:

Who was last car financed throug?

Present Auto

Year

Make

Model

Is this vehicle being used as a trade?

Yes

Primary Driver of New Purchase:

If no, why?

I understand the Federal Privacy Act, or other laws, rules or regulations may prohibit your disclosure of information regarding myself without my express approval and authority. You may consider this application as our authorization to release any information concerning myself to Bargain Spot Center, Inc. Bargain Spot Center and their lenders are authorized to investigate my (our) credit record(s) and to verify the information given above. I (we) certify that the statements made above are true and correct.