Revolving Charge Application

Revolving Charge Application
Type of account*

IndividualJoint
Email*
example@example.com
Applicant Name*

First NameLast Name
Co-Applicant Name

First NameLast Name
Present Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Select one*

Own HomeMobile HomeRentRoomLive with parents
Monthly Mortgage or Rent *
Years at this address
Mortgage Holder or Landlord
Former Address (if less than 3 years at present address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Years at this address
Social Security Number
Date of birth

MonthDayYear
Date
Number in Family
Others Authorized to Use Account
Complete for Applicant

Income from alimony, child support or maintenance payments need not be disclosed.
Employer's Full Name*
Business Phone
Please enter a valid phone number.
Position
Gross Salary*
Net Salary*
Years of Employment*
Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer's Full Name
(If less than 3 years at current employer)
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Other Income Source
Amount $ ______ Per _____
Other Income Source
Amount $ ______ Per _____
Complete for Co-Applicant if Joint Account is Requested
Employer's Full Name
Business Phone
Please enter a valid phone number.
Position
Gross Salary
Net Salary
Years of Employment
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number
Date of Birth

MonthDayYear
Date
Number of Dependents
Other Income Source
Amount $ ______ Per _____
Credit Information

	Name	Location	Names on Account	Account Number	Balance	Monthly Payment
1
2
3
4
5

Bank - Branch
Account Number
Checking/SavingChecking OnlySavings OnlyLoan
Nearest Relative

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship
American Home and Hardware

Your new charge account gives you all the convenience of extended payment shopping.

Charge Account Contract

I hearby make application for a charge account and agree:

1. To pay the full amount shown in the new balance block of my monthly statement by the 25th of the month following the statement date or elect to pay option terms. I understand I can, at any time, avoid FINANCE CHARGES by paying the entire new balance as shown on my monthly statement.

2. FINANCE CHARGES at an ANNUAL PERCENTAGE RATE are 18% which is a monthly "periodic rate" of 1 1/2%.

General – FINANCIAL CHARGES are applied to your average daily balance by adding your balances for each day in the billing cycle and then dividing by the number of days in the billing cycle. If customer chooses to pay less than the entire new balance, the minimum payment shall be 15% if the new balance plus the FINANCE CHARGE, or a minimum payment of $15.00 plus the FINANCE CHARGE on balances less than $100. Payments will be applied first to FINANCE CHARGES, and then to sales balances then outstanding.

3. You may do a credit investigation of my credit history and capacity and furnish information concerning this account to credit reporting agencies and others who may properly receive that information.

4. That, in the event I/we fail to make any monthly payment, in accordance with the payment chart, the entire balance will be due, American Home and Hardware and my/our privilege to further charge may be suspended. In such event, if this account is referred to an attorney or outside collectin agency for collections, I/we agree to pay expenses of collections, 20% collection fee, and attorney fees.

For important information regarding your right to dispute billing errors, see below.
Applicant Signature*

Powered by Jotform SignClear
Today's Date

MonthDayYear
Date
Co-Applicant Signature

Powered by Jotform SignClear
Today's Date

MonthDayYear
Date

In Case of Errors or Inquiries About Your Bill
The Federal Truth-in-Lending Act requires prompt correction of billing mistakes.
1. If you want to preserve your rights under the Act, here's what to do if you think your bill is wrong or if you need more information about an item on your bill:
  1. Do not write on the bill. On a separate sheet of paper write (you may telephone your inquiry but doing so will not preserve your rights under this law) the following:
    
    Your name and account number (if any)
    
    A description of the error and an explanation (to the extent you can explain) why you believe it is an error. If you only need more information, explain the item you are not sure about and, if you wish, ask for ecidence of the charge such as a copy of the charge slip. Do not send in your copy of the sales slip or other document unless you have a duplicate copy for your records.
    
    The dollar amount of the suspected error.
    
    Any other information (such as your address) which you think will help the creditor to identify you or the reason for your complaint or inquiry.
  2. Send your billing error notice to the address on your bill which is listed after the words: "Send Inquiries To:" or similar wording. Mail it as soon as you can, but in any case, early enough to reach the creditor within 60 days after the bill was mailed to you. If you have authoiruzed your bank to automatically pay from your checking or savings account any credit card bills from that back, you can stop or reverse payment on any mount you think is wrong by mailing your notice so the creditor receives it within 16 days adter the bill was sent to you. However, you do not have to meet this 16 day deadline to get the creditor to investigate your billing error claim.
2. The creditor must acknowledge all letters pointing out possible errors within 30 days of receipt, unless the creditor is able to correct your bill during that 30 days. Within 90 days after receiving your letter, the creditor must either correct the error or explain why the creditor believes the bill was correct. Once the creditor has explained the bill, the creditor has no further obligation to you even though you still believe that there is an error, except as provided in paragraph 5 below.
3. After the creditor has been notified, neither the creditor nor an attorney nor a collection agency may send you collection letters or take other collection action with respect to the amount in dispute; but periodic statements may be sent to you, and the disputed amount can be applied against your credit limit. You can not be threatened with damage to your credit rating or sued for the amount in question, not can the disputed amount be reported to a credit bureau or to other creditors as delinquent until the creditor has answered your inquiry. However, you remain obligated to pay the parts of your bill not in dispute.
4. If it is determined that the creditor has made a mistake on your bill, you will not have to pay any finance charges on any disputed amount. If it turns out that the creditor has not made an error, you may have to pay finance charges on the amount in dispute, and you will have to make up any missed minimum or required payments on the disputed amount. Unless you have agreed that your bill was correct, the creditor must send you a written notification of what you owe; and if it is determined that the creditor did make a mistake in billing the disputed amount, you must be given time to pay which you normally are given to pay undisputed amounts before any more finance charge or late payment charged on the disputed amount can be charged to you.
5. If the creditor's explanation does not satisfy you and you notify the creditor in writing within 10 days after you receive his explanation that you still refuse to pay the disputed amount, the creditor may report you to credit bureaus and other creditors and may pursue regular collection procedures. But the creditor must also report that you think you do not owe the money, and the creditor must let you know to whom such reports were made. Once the matter has been settled between you and the creditor, the creditor must notify those to whom the creditor reported you as delinquent of the subsequent resolution.
6. If the creditor does not follow these rules, the creditor is not allowed to collect the first $50 of the disputed amount and finance charges, even if the bill turns out to be correct.
7. If you have a problem with property or services purchased with a credit card, you may have the right not to pay the remaining amount due on them, if you first try in good faith to return them or give the merchant a chance to correct the problem.
STATE AND LOCAL LAWS

The foregoing summary of your rights under Federal law does not cover any rights you may have under State and Local Law, if, under State or Local law, you have a longer period of time in which to send an inquiry to the creditor concerning your bill, reliance of any such longer time period may result in your losing important rights which could be preserved by acting more proptly under Federal Law. State or Local law provisions, if any, only become operative upon the expiration of the time period provided by Federal Regulation Z.
Should be Empty:

Revolving Charge Application

Complete for Applicant

Complete for Co-Applicant if Joint Account is Requested

Credit Information

American Home and Hardware

Charge Account Contract