SELLER:     Location Credit Line Requested: $ Salesperson # Approval #                  Account #    

A married person may apply for individual credit.

APPLICANTS FIRST NAME:   MIDDLE: LAST NAME:
SOCIAL SECURITY NUMBER: DATE OF BIRTH:
            HOME TELEPHONE: 
            CURRENT ADDRESS: APT # :
            CITY:                         STATE: ZIP CODE:
            APPLICANT              Rents Owns           TIME AT ADDRESS: yrs. mos.
            MONTHLY RENT OR MORTGAGE PAYMENT $

IF APPLICANT OWNS OR IS BUYING:
CURRENT HOME VALUE: $ MORTGAGE BALANCE: $
PREVIOUS ADDRESS (if less than two Years at present address): APT #
CITY: ST: ZIP CODE:
NEAREST RELATIVE NOT LIVING WITH YOU: RELATIONSHIP:
CURRENT ADDRESS: APT #:
CITY: ST: ZIP CODE:
HOME TELEPHONE:

EMPLOYMENT INFORMATION
EMPLOYER NAME: POSITION: HOW LONG? vrs: mos.:
GROSS MONTHLY INCOME: BUSINESS TELEPHONE:
PREVIOUS EMPLOYER: HOW LONG?: FROM: (rno.yr. TO: rno./yr.): TO:

FINANCIAL INFORMATION
ADDITIONAL MONTHLY INCOME: SOURCE:
DO YOU HAVE A:   CHECKING ACCOUNT?   SAVINGS ACCOUNT?
NOTE: Alimony, child support or separate maintenance income need not be disclosed if you do not wish to have it considered as a basis for paying this obligation.

Complete for JOINT CREDIT or if you are a MARRIED WISCONSIN RESIDENT or INDIVIDUAL CREDIT (but relying on income of another)
FIRST NAME: MIDDLE: LAST NAME:
SOCIAL SECURITY NUMBER: DATE OF BIRTH:
HOME TELEPHONE: CURRENT ADDRESS: APT #:
CITY: STATE: ZIP CODE:
JOINT APPLICANTS EMPLOYER NAME: POSITION:
HOW LONG?: Yrs: Mos: BUSINESS TELEPHONE:

Notice to Applicant:
A consumer report may be requested with the processing of your Credit Application. Upon request, you will be informed whether or not a consumer report was requested and, if such report was requested, informed of the name and address of the consumer reporting agency that furnished the report. Subsequent consumer reports may be requested or utilized in connection with an update, renewal or extension of credit or collection. I/We authorize you to investigate credit and employment history and understand that if I/we do not qualify for the requested amount, you may consider me for a lesser amount.

If this application is approved you agree to all the terms and conditions of the attached Agreement (Form 23468-A (04/01)) which are incorporated herein by reference.

NOTICE TO THE BUYER: 1. DO NOT SIGN THIS APPLICATION BEFORE YOU READ THE ATTACHED AGREEMENT OR IF IT CONTAINS ANY BLANK SPACES. 2. YOU ARE ENTITLED TO A COMPLETELY FILLED IN AND EXACT COPY OF THE AGREEMENT WHEN YOU SIGN THIS APPLICATION. 3. KEEP THIS AGREEMENT TO PROTECT YOUR LEGAL RIGHTS. 4. YOU HAVE THE RIGHT TO PAY IN ADVANCE THE FULL AMOUNT DUE. THE AMOUNT WHICH IS OUTSTANDING WILL BE FURNISHED UPON REQUEST. 5. SERVICE CHARGES (FINANCE CHARGES) NOT IN EXCESS OF THOSE Permitted BY LAW MAY BE CHARGED ON THE OUTSTANDING BALANCES FROM MONTH TO MONTH.  6. IF YOU DO NOT MEET YOUR CONTRACT OBLIGATIONS, YOU MAY LOSE the PROPERTY YOU BOUGHT UNDER THIS CONTRACT. 7. THE SELLER HAS NO RIGHT TO ENTER UNLAWFULLY YOUR PREMISES OR COMMIT ANY BREACH OF THE PEACE TO REPOSSESS GOODS PURCHASED UNDER THIS Agreement 8. IF YOU DESIRE TO PAY OFF IN ADVANCE THE FULL AMOUNT DUE, THE AMOUNT THAT IS OUTSTANDING WILL BE FURNISHED UPON REQUEST.

BY YOUR ELECTRONIC SIGNATURE BELOW (RECOGNIZED BY CLICKING THE SUBMIT BUTTON), YOU ACKNOWLEDGE THAT YOU HAVE READ AND RECEIVED A COPY OF THE AGREEMENT BEFORE MAKING ANY PURCHASES UNDER THIS ACCOUNT; THAT ALL OF THE INFORMATION FURNISHED ON THIS APPLICATION IS, TO THE BEST OF YOUR KNOWLEDGE, COMPLETE AND ACCURATE; AND THAT NO PERSON HAS ASSISTED YOU IN ARRANGING this FINANCING.

BUYER'S RIGHT TO CANCEL:  IF THIS BOX IS CHECKED, YOU, THE BUYER, MAY CANCEL THIS TRANSACTION AT ANY TIME PRIOR TO MIDNIGHT OF THE THIRD BUSINESS DAY AFTER THE DATE OF THIS TRANSACTION. SEE THE SEPARATE NOTICE OF CANCELLATION FORM FOR AN EXPLANATION OF THIS RIGHT.

CAUTION - IT IS IMPORTANT THAT YOU THOROUGHLY READ THE AGREEMENT BEFORE YOU ELECTRONICALLY SIGN BELOW BY CLICKING THE SUBMIT BUTTON.

Date : Applicants Drivers License #:

 Joint Applicants Driver's License #: