Credit Application Form

Please fill in all pertinent information. Use the 'Comment' box for description of product/service you request, then hit the 'submit' button to send to us via email.

You can print this application and fax to us at: 207-858-0733.

You can print this application and U.S. Mail to us at: P. O. Box 687, Skowhegan, Maine 04976-0687.

If you would rather call us with the information - 207-474-0828 .

Applicant Name:

Date of Birth:

Applicant Street Address:

City, State, Zip:

, How Long: Previous:
Phone: FAX: E-Mail:

Co-Ap Name:

Date of Birth:

Co-Ap Street Address:

City, State, Zip:

, How Long: Previous:
Phone: FAX: E-Mail:

Note: If Applicant and Co-Applicant have separate credit, a separate credit application should be prepared for the Co-Applicant.

Housing Status:

Value: Info: If Other:
Monthly Rent/Mtg Payment $

Applicant's
Employment

Employer's Name: Years: Mo/Income:
Address: Phone:
Previous Employer - Address:

Co-Applicant's
Employment

Employer's Name: Years: Mo/Income:
Address: Phone:
Previous Employer - Address:

Source of
Other Income:

- Note: Alimony, child support or separate maintenance income need not be disclosed if you do not wish to have it considered as basis for repaying this obligation.

Declaration:

Has Applicant Or Co-Applicant Declared Bankruptcy:

Contact

If Other:

Certification of Identification
If the customer provides a current photo driver's license, and it shows name, address, and date of birth, then no other ID is required. If the cusotmer does not have a current photo driver's license, then another form of picture ID is required, as well as ID that verifies both address and date of birth. This may require collecting 2 forms of ID.

ACCEPTABLE FORMS OF ID: Other ID - BOTH address and DOB need to be verified:

Current Driver's License Social Security Card Real Estate Tax Receipt

State ID Birth Certificate Recent IRS W-1

Military ID Utility Bill - dated w/in 90 days Immigration Documents

Valid Passport Marriage License

Signature/Typed Name of Certifier -

Title Date

Applicant Co-Applicant

Name: Name:
Drivers License # Drivers License #
Social Security # Social Security #
Other (Describe) Other (Describe)
Document # Document #
Date of Issue Date of Issue
Expiration Date: Expiration Date:

Comments:

Please note - we may require more information.

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