Fitzpatrick's Furniture Credit Application

Date
Items Purchasing

Tell Us About Yourself

First Name*
Last Name*
Date of Birth*
Social Security Number*
Home Phone*
Cell Phone
Email Address
Street Address*
City, State and Zip Code*
Time at Residence
Resident Status
(Select One)
If Other,
Please Explain
Monthly Payment*
Landlord/ Mortgage Co. Name/ Phone Number
Employers Name
Phone Number
Job Title
Time on Job
Work Address
Hourly Pay
Are you paid: Weekly
Bi-Weekly
Monthly
Additional Income
(Please Explain)
Bank Name
Checking Account Yes
No

Other Info

Car
Car Payment*
Yes
No
Amount
Financed Thru

Co-Applicant

First Name
Last Name
Date of Birth
Social Security Number
Home Phone
Cell Phone
Street Address
City, State and Zip Code
Time at Residence
Employers Name
Phone Number
Job Title
Time on Job
Work Address
Hourly Pay
Are you paid: Weekly
Bi-Weekly
Monthly
Additional Income
(Please Explain)

How Did You Hear About Us?

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Search Engine
Referrals (Former/Current Customer)
Facebook
Other

    

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