PERSONAL INFORMATION

Your First Name (and middle initial if used)

Your Last Name

Best Contact Phone Number

2nd Best Phone Number

Date of Birth (mm-dd-yyyy)

Social Security Number

Drivers License Number

Email Address

Spouse First Name (and middle initial if used)

Spouse Date of Birth

YOUR HOME

Street Address

Apartment Number

City

State

Zip Code

YOUR EMPLOYMENT

Current Employer

Employer Phone Number

Your Occupation

Length of Current Employment (years-months)

Employer Address (city-state-zip)

Previous Employer (if current is less than 5 years)

Spouse Employer

Spouse Employer Address (city-state-zip)

Message

By submitting this application for credit, you are authorizing Kaybee of Macon 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 phone or email, regarding your credit approval or should additional information be required.

I understand that if my credit is approved I must provide proper identification 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 Kaybee of Macon’s organization only, and will be processed at our store.