mime-version: 1.0 content-location: file:///C:/CCE46A32/CreditApplication-wp2.htm content-transfer-encoding: quoted-printable content-type: text/html; charset="us-ascii" CREDIT APPLICATION

CREDIT APPLICATION=

 

In order for our office to properly consider your request for credit, the following information must be provided:<= /o:p>

 

NAME __________________________________________________ DATE ________________

How long have you lived at your current add= ress?  ____Years _____Months<= /span>

Regarding your present home, do you: ___ OW= N or ___ RENT this property?

 

Previous Address________________________________________________________________

 

EMPLOYMENT  Current Employer: ________________________________________________

  = ;            &= nbsp;           &nb= sp;            = ;                 = ;            &= nbsp;           &nb= sp;            = ;         Yrs.  = ;          Mos.=

How long have you been employed at your cur= rent employment?______           ______

  = ;            &= nbsp;           &nb= sp;            = ;                 = ;            &= nbsp;           &nb= sp;            = ;   Length &n= bsp; Yrs.            =     Mos.

Previous Employer_____= ____________________________of work ______      =        ________

 

SPOUSE  Your Spouse's Name and Employer: ________________________________________<= /o:p>

 

___________________________________________= ___________________________________

 

BANK  Name of your Bank: _______________________________________________________=

 

REFERENCES _______________________________________________________= ___________

 

FINANCIAL TERMS: How would you like to pay for your servic= es in our

 

office?  Amount: $______________ every____________ (Both blanks must be completed.)

 

** NOTE: Completing this application does n= ot guarantee that credit will be given, or that the terms <= /p>

you've requested will be granted.

 

Office Staff Recommendation: _____________________________________________________

 

Doctor's Approval and Terms: _____________________________________________________

 

NOTE:  This agreement must be approved before glasses or contact lenses ca= n be ordered.  A

rebilling<= /span> charge of $2.00/month will be charged after 60 days past due.

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I hereby accept the Extended Payment Plan outlined below and agree to make payments as

scheduled<= /span>.  I understand that if I fail to ma= ke these payments my account will be turned over to an attorney, <= /span>

in<= span style=3D'font-size:12.0pt;mso-bidi-font-size:10.0pt;font-family:"Times New= Roman"'> which case I will be obligated to pay the costs of collection, court, and = legal fees

in addition to the balance owed in this off= ice.

 

Total Fees: $______________ Amt. Paid: $______________ Total Loan: $______________

 

I agree to pay $______________ every _____________________________________.

 

        = ;      ______________________________________________     ___________

        = ;            &= nbsp;         = ;      Account Responsible Signature        = ;         = ;                   Date