Credit Application Ken K. Thompson Jewelry - Formstack

1080 Paul Bunyan Drive NW, Bemidji, Minnestoa 56601 Phone (218)751-1433

CREDIT APPLICATION

Please submit your credit application 24 hours prior to ordering.

Upon completion and submission of your application,

Ken K. Thompson Jewelry will contact you with approval status.

Credit Application
PERSONAL INFORMATION
First Name *
Middle Name *
if not middle name "NONE"
Last Name *
Date of Birth
Month
Day
Year
SSN (###-##-####) *
Confirm SS# *
Phone / Cell *
###-###-###
Primary Email *
Current Address Information
Address Line 1
City
State
ZIP Code
Own

Own Rent
Monthly Mortgage / Rent *
How Long Lived There? (Months) *

EMPLOYMENT INFORMATION
Current
Employer Name *
Address Line 1
City
State
ZIP Code
Current Employer Phone *
Monthly Income from this Employer *
How Long Employed at Current Position? (Months) *
Current Position

Previous Employer - if less than 12 months at current employer
Employer Name
Address Line 1
City
State
ZIP Code
Monthly Income from Previous Employer
Previous Position
How long at this last Position (Months)

ADDITIONAL INFORMATION
Drivers Licenses or State ID *
Government ID Issued by *
Expiration Date
Month
Day
Year
Major Credit Card Issuer
Visa

Visa MasterCard Discover American Express
Expiration Month
Expiration Year

OTHER SOURCES OF INCOME
Amount per Month
Description (if none please indicate "NONE")

CUSTOMER AUTHORIZATION
Signature

Clear
Date

Month Day Year
Date
Should be Empty:

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