CUSTOMER CREDIT APPLICATION

This Form is presented as a representation of the following print application. In all cases terms within the pdf attached here supercede what is in the digital version.*

I accept the preceding statement.*

I accept.

Each applicant may apply for individual or joint credit regardless of marital status. This application is for:*

Individual Credit - complete applicant information.Joint Credit with Spouse as Joint Applicant - complete applicant and co-applicant information.Joint Credit with Non-Spouse as Joint Applicant - complete applicant and CO- applicant information

We intend to apply for joint credit:

Applicant Sign Here*

Co-applicant Sign Here*

Applicant's identification was verified via viewing an unexpired driver's license unless one of the following is checked: Unexpired:

State Issued ID CardPassportSocial Security Card

Co-Applicant's identification was verified via viewing an unexpired driver's license unless one of the following is checked: Unexpired:

State Issued ID CardPassportSocial Security Card

Verified By:

Dealer #

Initial Sale $

Down Payment $

In this Agreement "you" and "your" refer to all persons applying for credit and "we, "us", and "our" refer to Dealer and its assigns.

Are you a US Citizen?*

NoYes

No of Dependents*

Social Security Number*

Date of Birth*

Date

Email Address*

example@example.com

First Name*

Middle*

Last Name*

Residence Address No PO Box allowed*

Time at Residence...

Years blanks* Monthsblank*

City*

State*

Zip*

Rent or Own?*

OwnRent

Monthly Mortgage Payment*

Does Payment Include Taxes/Insurance?*

YesNo

If it does not include, how much is that?*

$ Dollars

Home Value*

Home Phone*

Cell Phone*

Work Phone*

Present Employer*

Occupation*

Gross Monthly Salary $*

Length of employment is blanks* years and blank* months.

Alimony, child support or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation. Other Income Source Monthly Amount

Other Income $*

Source*

Monthly Amount $*

Drivers Lic No*

State*

Issue Date*

Date

Expiration Date*

Date

Are you a US Citizen?*

NoYes

No of Dependents*

Social Security Number*

Date of Birth*

Date

Email Address*

example@example.com

First Name*

Middle*

Last Name*

Residence Address No PO Box allowed*

Time at residence in Years, and Months

Yrs*

Mos*

City*

State*

Zip*

Home Phone*

Cell Phone*

Work Phone*

Present Employer*

Occupation*

Gross Monthly Salary*

Length of employmentblanks yearsblank* months

Other Income $*

Source*

Monthly Amount*

Drivers Lic No*

State*

Issue Date*

Date

Expiration Date*

Date

By signing this application, you warrant that all information provided is true and complete.
You authorize the Dealer to assign this application to Aqua Finance, Inc. (“AFI”) or its assigns, and you authorize a full investigation and release of any records from any source, including credit bureau reports, to verify the accuracy of the information on this application.

You consent to receiving autodialed message calls from us or our agents on your wireless phone and agree to keep us informed of any changes to the information you provided.

By completing and signing this application, you understand that you are requesting we open a revolving credit account allowing you to make credit purchases as evidenced by a revolving credit sales slip. You agree to all terms and conditions of the Revolving Credit Agreement and acknowledge that you have received and read all terms before making any purchases on the account.

If this is a joint account, you understand that each applicant has the right to use the account up to the credit limit and that both of you are jointly and severally liable for all purchases.

See State Notices for important information regarding this credit application and agreement. No agreement exists between us until this application is approved.

SOCIAL SECURITY NUMBER / TAXPAYER IDENTIFICATION NUMBER
Under penalties of perjury, you certify that:

The number provided on this Credit Application is your correct taxpayer identification number (or you are waiting for one to be issued).
You are not subject to backup withholding because you are exempt, you have not been notified by the IRS that you are subject to backup withholding due to failure to report interest or dividends, or you have been notified that you are no longer subject to backup withholding.

You are a U.S. person (including a U.S. resident alien).
Certification Instructions: Cross out item 2 if the IRS has notified you that you are currently subject to backup withholding. Cross out item 3 and complete a W-8 BEN if you are not a U.S. person.

Your minimum monthly payment will be between 1% and 5% of the “Highest Monthly Charge” balance (excluding any Special Payment Plans) as shown on your billing statement, rounded to the next dollar, or $15, whichever is greater.

If you participate in a Promotional Plan, your minimum monthly payment will be between 1% (for the first 12 months) and 2% (thereafter) of the “Highest Monthly Charge” balance, or $15, whichever is greater. A finance charge will be computed on your outstanding balance each month.

The IRS does not require your consent to any provision of this document other than the certification required to avoid backup withholding.

DO NOT SIGN BELOW UNLESS MURCHANT HAS PROVIDED THE ATTACHED DISCLOSURE AND TERMS. BY YOUR SIGNATURE BELOW YOU ACKNOWLEDGE RECEIPT OF THE ATTACHED REVOLVING CREDIT AGREEMENT.

Applicant Signature*

Date*

Date

Joint Applicant Signature

Date

ASSIGNMENT & MEMBERSHIP
Should Aqua Finance, Inc. (“AFI”) acquire your account, AFI may further assign your credit transaction. AFI, acting as an extension of the lending operations of Connexus Credit Union (“Connexus”) and the Connexus Association (“Association”), may assign it to them.

If your credit transaction is accepted by Connexus, you agree to become a member of both entities and to the terms of such memberships. A deposit account in your name will be created to hold the membership par amount of $5.00, and you will receive a free two-year membership in the Association, both paid on your behalf by AFI.

Applicant Signature*

CREDIT REPORT NOTICE: We may request a credit report for any legitimate purpose associated W your application for credit, extending credit, modifying the terms of your credit agreement, or collecti Mos. on your account. On your request we will inform you if such a report was ordered and will give you t name and address of the credit reporting agency that furnished the report. NOTICE: The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against cre applicants on the basis of race, color, religion, national origin, sex, marital status, age (provided t applicant has the capacity to enter into a binding contract); because all or part of the applicant's incor derives from any public assistance program; or because the applicant has in good faith exercised a right under the Consumer Credit Protection Act. The Federal agency that administers compliance W the law concerning this creditor is the Federal Trade Commission.

Delaware residents: Service charges not in excess of those permitted by law will be charged the outstanding balances from month to month.

Maryland residents: Finance charges will be made in amounts or at rates not in excess of the permitted by law.

Customer Credit Application

Revolving Credit

DEALER USE ONLY

CUSTOMER CREDIT APPLICATION

CO-APPLICANT INFORMATION (For Joint Applications Only)