Credit Request Form

All Fields Marked with a Red * Are Required. Please use the TAB key to move from one field to the next

Customer Information
First Name * Middle Name Last Name * Generation
Social Security *
- -
Date Of Birth(mm/dd/yyyy) *
/ /
Home Phone
- -
Cell Phone
- -
Email Address: * Re Enter Email Address: *
Current Address
Address * Apt/Flr City * State * Zip * Years at Address *
yr - mo
Previous Address If Less Than 3 Years At Current Address
Address Apt/Flr City State Zip
Customer Reference
First Name * Last Name * Phone* Relationship*
- -
Address* City* State* Zip*
Employment Information
Employer *
Address * City * State * Zip *

Phone *
- -

Job Title *
Time on Job
(years) *
yr - mo
Verifiable Monthly
Income *
Amount of
Financing Requested
BY CLICKING SUBMIT, I/We have completely and correctly answered all of the questions on this application and understand that Capitol Discount will rely on the answers given. During the review of my application, Capitol Discount may obtain a credit report on me, and if my application is approved, Capitol may at any time in the future obtain any additional credit reports to review my account. I/We have the right to ask for the name and address of the credit reporting agency which gave Capitol the credit report. This application will be processed by and remain the property of Capitol Discount. By signing this applicatlon, I/We authorize my employer to release personal employment information regarding my tenure, salary, occupation, and garnishee record (if any) to Capitol Discount. I understand that my employer's reply will be held in confidence end wlthout liability to my employer. I/We also authorize you to release to and or obtain from third parties any information disclosed on this application, my transactions with you, and my transactions with third parties.