DISCOUNT FURNITURE ON-LINE CREDIT APPLICATION

   A  B  O  U  T      Y  O  U 

Title

(ie: Mrs.)

First Name

Initial

Last Name

Date of Birth

(ie:  12/25/1975)

Social Security Number

Street Address

Apt #

City

State

Zip Code

Monthly Rent / Mortgage

How long at current  address?

Home Phone

Cell Phone

Work Phone

E-Mail Address

Years

Months

   A  B  O  U  T      Y  O  U  R      E  M  P  L  O  Y  M  E  N  T

Name of Current Employer

Occupation

Monthly Net Salary

How long with this employer?

Years

Street Address

City

State

Zip Code

Employer's Phone

   O  T  H  E  R     I  N  C  O  M  E   (optional)

NOTE: Alimony, child support or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for paying this obligation.

Other Monthly Income Amount

Source of Other Income

   S  T  O R  E     L  O  C  A  T  I  O  N

DISCOUNT FURNITURE

By submitting this application for credit, you are authorizing DISCOUNT FURNITURE to obtain consumer credit report (s) and to verify the information herein.   Please be sure that all the information stated is correct before submitting.  A member of our Credit Department will contact you, by the preferred method you have selected above, regarding your credit approval or should additional information be required.

I understand that if my credit is approved I must provide proper identification to the appropriate retail store and will be required to sign a credit agreement upon purchase. 

This data is for the sole purpose of determining your credit status and will be used within the DISCOUNT FURNITURE organization only, and will be processed at the Store Location you selected above.  DISCOUNT FURNITURE protects your information during transmission to us through an encryption process developed specifically for this purpose.