Personal Data
Name (last, first, middle) __________________________________________________________________________________
Social Security Number - - Birthdate _____/_____/______ Number of Dependent/Ages________
Mailing Address_____________________________________ City ______________ State ____ Zip______ Years_____
Physical Address ____________________________________ City ______________ State ____ Zip______ Years_____
Home Phone ( )_______________________________ Work Phone ( )___________________________
Have you ever delcared Bankruptcy? ____________ Had a Repossession? ___________ Judgement?___________
Email Address _______________________________________________________
Registered in which Shooting Association?_______________________ Membership #________________________
Driver's License Number____________________________________ Exp. Date ____________ State_________
Employment History
Employer_____________________________________________
Years at this Company____________________
Address_______________________________________ City______________
State__________ Zip________
Phone ( )________________________ Title_____________________
Salary/Wages(Gross)______________
Previous Employer______________________________________
Years at this Company____________________
Address_______________________________________ City______________
State__________ Zip________
Personal and Credit References
Personal Reference: Name_______________________________________
Relationship_______________________
Address____________________________ City___________________ State___________ Zip_______________
Name of Creditor/Credit Card_________________________ Exp. Date ______ Account Number__________________
Address/Branch___________________________________________________________________________________
Date Opened__________________________ Balance__________________ Monthly Payment__________________
I certify that the statements herein are true and that I am not liable for any debts, other than specifically listed. Pacific Sporting Arms is authorized to obtain any information which it deems necessary for consideration of the credit request and during the credit transaction, if approved.
Signature________________________________________________________________
Date_____________
