2 Calhoun Street • P. O. Box 384 • Washington Depot, CT 06794 Phone : (860) 868—7395 Fax: (860) 868—2163 Email:
[email protected] www.washingtonsupply.com
Credit Line Requested:_________________ Full Name:_____________________________________________________________ DOB:__________________________________ Present Street Address______________________________________________________________ Email:______________________ City:______________________________ State:__________ Zip Code:_________________ Years at present address:_____________ Billing Address:_____________________________________________________________ Social Security #_____________________ City: ______________________________ State: __________ Zip Code:_________________ Home Phone: _____________________ Billing Phone Number:________________________ Cell Phone:________________________ Would you like e-statements? □
Employment Present Employer:_______________________________________________________________________________________________ Position:_______________________________________________________ Name of Supervisor:_______________________________ Employer’s Address:______________________________________________ _______________________________________________ City:_________________________________________State:________________________ Zip Code:_____________________________ Employer’s Phone Number:_______________________________________________________________________________________
Banking Information Checking Account Number:_____________________________________ Bank and Branch:_______________________________________________ Phone Number:____________________________________ Savings Account Number:______________________________________ Bank and Branch:__________________________________________ _____Phone Number:___________________________________
Persons authorized to charge on this account. You are required to contact us with any changes. Name:________________________________________ Name: __________________________________________ Name:________________________________________ Name:___________________________________________ Name:________________________________________ Name:___________________________________________ Name:________________________________________ Name:___________________________________________
Credit References Name:_________________________Address:___________________________________ Phone #_____________________ Name:_________________________Address:___________________________________ Phone #_____________________ Name:_________________________Address:___________________________________ Phone #_____________________
The Supply, Inc. Homeowner Credit Application.
If this is a Joint Account, or if the account is to be used by more than one person: Joint Applicant’s Name:__________________________________________________________ Joint Applicant’s Social Security Number:____________________________________________ AGREEMENT Everything that I have stated in this application is correct to the best of my knowledge. I understand that The Supply, Inc. will retain this application whether or not it is approved. The Supply, Inc. is authorized to check my credit and employment history. I agree to pay all charges placed on my account within thirty days of the date of the monthly statement. I also agree to pay any and all service charges at the rate stated on the statements when tendered. Should it be necessary, I also agree to pay all collection costs, including attorney’s fees to facilitate collection of my account.
________________________________________ Applicant’s Signature ________________________________________ Joint Applicant Signature
_________________ Date _________________ Date
