Individual Credit Application - State Of Indiana

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INDIVIDUAL CREDIT APPLICATION
RETURN TO:
Premier Ag Co-op, Inc.
DBA:
Premier Companies
Premier Energy
Heyob Energy
P.O. Box 1947 • Columbus, IN 47202
Branch ____________________________________________________
812-379-9501 • Fax 812-372-6801
1.
APPLICANT
Name _______________________________________________________
Birth Date ___________________________________________
Address ____________________________________________________
Social Security No. _____________________________________
City _______________________ State __________ Zip ___________
Home Phone __________________________________________
Previous Address _____________________________________________
Years at Present Address _________________________________
City _______________________ State __________ Zip ___________
Years at Previous Address ________________________________
Employer __________________________________________________
Previous Employer _____________________________________
Address ___________________________________________________
Address ______________________________________________
Phone ______________________________________________________
Phone _______________________________________________
Position _____________________________ Years There ______________
Position _________________________ Years There __________
Monthly Take Home Pay ______________________________________
Other Income* _________________________________________
2.
CO-APPLICANT
Name _______________________________________________________
Birth Date ___________________________________________
Address ____________________________________________________
Social Security No. _____________________________________
City _______________________ State __________ Zip ___________
Name of nearest relative not living with you or personal reference
Employer __________________________________________________
________________________________________________________________
Address ___________________________________________________
Address ______________________________________________
Phone ______________________________________________________
City __________________ State __________ Zip ___________
Position _____________________________ Years There ______________
Relationship __________________________________________
Monthly Take Home Pay ______________________________________
Phone ________________________________________________
* Alimony, child support or separate maintenance income need not be
Other Income* ________________________________________________
revealed if you do not wish it to be considered in determining your credit
worthiness.
3.
CREDIT REFERENCES (Please List Open Accounts First)
Name and Address
Original Balance
Current Balance
Monthly Payment
SEE REVERSE SIDE FOR ADDITIONAL TERMS AND CONDITIONS

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