* Dear Customer, Please Print this Credit Application. Fax it at (713) - 450 -1019
		Merchant No.		Office No.			Sale Amount
For Merchant Use
							$
Merchant Name				Date					Authorization No.
Tell Us About Yourself						CO-Applicant
First Name		Initial		Last Name		First Name		Initial		Last Name
Other Name Used For Credit			Home Phone			Other Name Used For Credit			Home Phone
			(      )						(      )
Date of Birth		Social Security No.				Date of Birth		Social Security No.
Street Address				Apt No.		Street Address				Apt No.
City		State		Zip		City		State		Zip
No. Dependents			Time at Residence			No. Dependents			Time at Residence
Residence Type    __ Own   __Rent  __Board						Residence Type    __ Own   __Rent  __Board
Mortgage/Rent Payment   $						Mortgage/Rent Payment   $
Your House Value $						Your House Value $
Mortgage Balance  $						Mortgage Balance  $
Mortgage Holder/Landlord Name and Address:						Mortgage Holder/Landlord Name and Address:
Tell Us About Your Income						Tell Us About Your Income
Employer Name:						Employer Name:
Occupation:						Occupation:
Employment Phone (      )						Employment Phone (      )
Time Employed        _____ Yrs.     ____ Mos.						Time Employed        _____ Yrs.     ____ Mos.
Employer Address:						Employer Address:
City		State		Zip		City		State		Zip
Employer Income  $                       Per Month						Employer Income  $                       Per Month
*Other Income (Specify Source)   $                     Per Month						*Other Income (Specify Source)   $                     Per Month
Driver's License Number:						Driver's License Number:
Nearest Relative  Not Living With You:						Nearest Relative  Not Living With You:
Address :						Address :
Phone Number (      )						Phone Number (      )
Relationship:						Relationship:
By signing below, you certify that all information given in this Appilcation is true and complete.  You also authorize us to confirm
the information in this Application and give out information about you or your Account to credit reporting agencies and others
who are allowed to receive it.  You authorize and instruct us to request and receive credit information about you from any credit
reporting agency or third party.
___________________________________________						______________________________________
Applicant Signature                               Date						Co-Applicant Signature                    Date