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FIRST NAME:
LAST NAME:
AGE:
STATE:
ZIP:
HOME PHONE: ( ) -
WORK PHONE: ( ) - EXT.
CELL PHONE: ( ) -
E MAIL:
EMPLOYER:
JOB TITLE:
TIME ON JOB:
JOB STATUS:
MARITAL STATUS:
CREDIT CARDS: None One Two Three Four Five or More
DEPARTMENT STORE CARDS: None One Two Three Four Five or More
AUTO LOANS PAID OFF OR CLOSED: None One Two Three Four Five or More
PLEASE LIST OTHER CREDIT, OR A BRIEF SUMMARY OF YOUR CREDIT HISTORY:
REPOSSESSIONS: None One Two Three Four Five or More
CHARGE OFFS: None One Two Three Four Five or More
MEDICAL COLLECTIONS: None One Two Three Four Five or More
OTHER COLLECTIONS: None One Two Three Four Five or More
BANKRUPTCY:
APPROXIMATE YEAR BANKRUPTCY DISCHARGED:
REASON FOR BANKRUPTCY:
GOOD CREDIT AFTER BANKRUPTCY:
BAD CREDIT AFTER BANKRUPTCY: