Streater-Smith Credit Application

Applicant Information

First Name:MI:
Last Name:
Email Address:
Home Phone:
Date of Birth:
Street Address:
Street Address 2:
City:

Zip:
SSN:
Drivers License:
Time at Current Residence:
Rent/Own:
Landlord or Mortgage Holder:
Monthly Housing Payment:

Employment Information

Employer:
Employer Phone:
Employer City:
Years with Company:
Income Before Tax:
Additional Source of Income:
Amount of Other Income:
Previous Employer:
Previous Employer City:

Financial Information

Bank:
Account Type:
Have you had a vehicle repossessed?
If so, when (mm/yy)?
Have you filed for bankruptcy?
If so, when (mm/yy)?

Credit Information

Creditor's Name City/State	Date Opened (mm/yy)	Monthly Payment	Unpaid Balance

Reference Information

Name and Address of Nearest Friend/Relative (Not in Household)	Phone Number	Relationship