PDF APPLICATION FOR CREDIT - EasyPay Finance

RETAILER/PROVIDER: CONTACT NAME: CONTACT PHONE#: CONTACT FAX#:

FIRST NAME

APPLICATION FOR CREDIT

(All fields must be completed to avoid processing delay)

MI

LAST NAME

HOME ADDRESS

CITY

STATE

ZIP CODE

BILLING ADDRESS

CITY

STATE

ZIP CODE

MOBILE PHONE NUMBER

HOME PHONE NUMBER

E-MAIL ADDRESS

SOCIAL SECURITY NUMBER

EMPLOYMENT STATUS: (check one)

EMPLOYER NAME

EMPLOYED

DATE OF BIRTH SELF-EMPLOYED

HOUSING STATUS: (check one)

OWN RENT

MONTHLY PAYMENT

OTHER _______________________________

GROSS MONTHLY INCOME

WORK PHONE

BANK NAME

BANK ROUTING #

CHECKING ACCOUNT #

REFERENCES REFERENCE #1 NAME (RELATIVE NOT LIVING WITH YOU)

RELATIONSHIP

REFERENCE #2 NAME (NON-RELATIVE)

RELATIONSHIP

PHONE NUMBER PHONE NUMBER

I HEREBY ACKNOWLEDGE that I am over the age of eighteen (18) years, and that all of the information set forth in this credit statement is true, accurate and a full and complete disclosure thereof. I HEREBY authorize the Merchant and/or its assignees to make all inquiries necessary to verify the accuracy of the statements made in the application and to determine any creditworthiness by obtaining consumer reports from consumer reporting agencies and information from others including creditors, financial institutions, references, employers, landlords and others identified in the application, (including any employee or agent of any of them). IN THE EVENT that credit is extended: (1) I hereby authorize any holder or assignee to obtain credit reports, in connection with the extension of credit, for the purpose of reviewing the account, taking collection action on the account, or for other legitimate purposes associated with the account; and (2) I acknowledge, as part of Merchant's information collection process, Merchant may detect additional bank accounts belonging to you. I FURTHER AUTHORIZE the Merchant and/or its assignees any attorney, debt collector or collection agency communicating any and all information concerning this application or debt to any credit reporting agency or other creditor. I FURTHER ACKNOWLEDGE AND AGREE, that I will notify the creditor or prospective creditor in writing of any change in my name, address or employment within a reasonable time thereafter. I agree that Merchant and its assignees may contact me in writing, by e-mail, or using prerecorded/artificial voice messages, text messages, and automatic telephone dialing systems, as law allows, I also agree that Merchant and it assignees may contact me in these and other ways at any address or telephone number I provide, even if the telephone number is a cell phone number or the contact results in a charge to me. Pursuant to the Fair Credit Reporting Act, I acknowledge and agree that my credit application may be submitted to Duvera Billing Services, LLC dba EasyPay Finance, located at PO Box 2549 Carlsbad, CA 92018-2549 (866) 337-2537, for consideration for the extension of credit.

X APPLICANT SIGNATURE

DATE

TO BE COMPLETED BY SELLER OF PRODUCT OR SERVICE UPON REVIEW OF APPLICANT'S GOVERNMENT ISSUED IDENTIFICATION:

APPLICANT'S GOVERNMENT ID #

EXPIRATION DATE

/

ISSUER/STATE

DATE OF BIRTH

/ /

SUBMIT CREDIT APPLICATION TO MERCHANT Client Services Phone: 866-337-2537 Opt. 5 Hours: Mon - Fri (8am - 7pm PT), Sat (8am - 4pm PT), Sun (Closed)

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