First Name:  MI:  Last Name: Suffix: 

Additional Surname: 

Date of Birth  (mm/dd/yyyy)

Marital Status Married Unmarried Separated

Contact Numbers where you can be reached:

Number:   Contact Type:HomeWorkCellOther

Number:   Contact Type:HomeWorkCellOther

Email: 

Current Mailing Address

Street:  

Street 2: 

City:  State:AlabamaAlaska ArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip: 

Number of Years At Current Residence:   Own Rent Live with Relatives Other

Previous Address (if less than 2 years at current address)

Street  

Street 2:  

City:  State:AlabamaAlaska ArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip: 

Number of Dependent Children 

Ages:

Name of Nearest Relative not living with you:  Relationship: 

City: 

State:AlabamaAlaska ArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip: 

Telephone Number: 

Current Employer:  

Street: 

Street 2: 

City:  State:AlabamaAlaska ArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip: 

Phone: 

Position/Title  Years Employed: 

Gross Monthly Income: 

Previous Employer: (if less than two years at current employer) 

Street: 

Street 2: 

City:  State:AlabamaAlaska ArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip: 

Telephone Number:  

Position/Title: 

Note: Alimony, Child support, or separate maintenance income need not be revealed unless you want them considered as a basis for repaying this obligation

Source:  Amount: $ 

Checking Account:  Account # 

Savings Account  Account#  

Landlord/Mortgage Holder Name: 

Phone Number:  Account # 

Monthly Payment:   

Next Largest Obligations:

1.   Phone: 

Account #  Payment:   Balance:  

2.   Phone: 

Account #  Payment:   Balance:  

3.   Phone: 

Account #  Payment:   Balance:  

4.   Phone: 

Account #  Payment:   Balance:  

5.   Phone: 

Account #  Payment:   Balance:  

CO-APPLICANT INFORMATION

First Name:  MI:  Last Name:  Suffix: 

Additional Surname: 

Date of Birth  (mm/dd/yyyy)

Marital Status Married Unmarried Separated

Contact Numbers where you can be reached:

Number:  Contact Type:HomeWorkCellOther

Number:   Contact Type:HomeWorkCellOther

Current Mailing Address

Street:  

Street 2: 

City:  State:AlabamaAlaska ArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip: 

Number of Years At Current Residence:   Own Rent Live with Relatives Other

Previous Address (if less than 2 years at current address)

Street: 

Street 2: 

City:  State:AlabamaAlaska ArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip: 

Number of Dependent Children 

Ages:

Name of Nearest Relative not living with you:  Relationship: 

City:  State:AlabamaAlaska ArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip: 

Phone: 

CO-APPLICANT EMPLOYMENT

Employer: 

Street: 

Street 2: 

City:  State:AlabamaAlaska ArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip: 

Phone: 

Position  Years Employed: 

Gross Monthly Income: 

Previous Employer: (if less than two years at current employer) 

Street: 

Street2: 

City:  State:AlabamaAlaska ArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip: 

Phone: 

Position: 

CO-APPLICANT’S OTHER INCOME

Note: Alimony, Child support, or separate maintenance income need not be revealed unless you want them considered as a basis for repaying this obligation

Source:  Amount: $ 

FINAL INFORMATION AND APPLICATION SUBMISSION

Fair Credit Reporting Act Notice to Consumer:
This will advise you that your retail installment contract and credit application will be submitted to West Valley View Inc., for purchase and consideration as to whether you meet their credit requirements.

Notice: To New York Residents. West Valley View Inc., may obtain a consumer report on you in connection with your credit application. Upon request by you, West Valley View Inc., will tell you whether or not a consumer report was obtained and the name and address of the consumer reporting agency that furnished the report.

I hereby declare that all of the statements made in this application are true and correct and are made for the purpose of obtaining credit. You are authorized to investigate my credit record, to verify credit, employment and income references, to obtain such other information as West Valley deems necessary, and to give credit reporting agencies (credit bureaus) and others information regarding your credit experience with me.