Consumer Application Form

CONSUMER APPLICATION FORM

Applicant Name:     Date of Birth:     Social Security Number (last 4):

Applicant Contact Information

Length of residence: years    months

Own    Rent    Other:

Residential History (if less than 3 years at current address)

Employment and Income

Position/Title:    Monthly Gross Income: $

Employment Start Date:    Employer Phone:

Financial Obligations

Total monthly obligations (approx.): $

References

Relationship:    Phone:

Relationship:    Phone:

Consents, Authorizations, and Certifications

By submitting this application, Applicant authorizes the recipient to verify the information provided, including but not limited to credit history, employment verification, rental and eviction history, consumer reports, and criminal background checks where permitted by law. Applicant expressly consents to the release of such information by current and former employers, landlords, credit bureaus, consumer reporting agencies, and other entities that may hold relevant records. Applicant's consent is continuing and may be relied upon until written revocation is provided.

Consent to Obtain Consumer Report: Applicant consents to the procurement of consumer reports for purposes of evaluating this application.

Consent to Contact: Applicant consents to contact references and employers for the purposes described above.

Declarations

Have you ever declared bankruptcy?   Yes   No

Are there any outstanding judgments against you?   Yes   No

Have you ever been subject to an eviction proceeding?   Yes   No

Privacy and Use of Information

Information collected on this form will be used solely to evaluate the Applicant's qualifications and for related administrative purposes. Applicant acknowledges that certain information may be retained in accordance with applicable record retention practices and that disclosures may be made where permitted or required by law. Applicant understands that sensitive personal data should be provided only as required and consents to the processing of the information for the stated purposes.

Acknowledgment and Certification

Applicant certifies under penalty of perjury that the information provided in this application is true, complete, and correct to the best of Applicant's knowledge. Applicant acknowledges that materially false statements or omissions may be grounds for denial of the application or subsequent termination of any agreement entered into based on this application.

Applicant Initials:

Governing Law and Other Provisions

Governing Law: This application and any resulting relationship shall be governed by and construed in accordance with the laws of the jurisdiction where the recipient maintains its principal place of business, without regard to conflict of law principles.

Entire Agreement: This application, any attachments, and any disclosures provided at the time of submission constitute the entire understanding between Applicant and the recipient with respect to the matters contained herein and supersede all prior representations and agreements, whether written or oral.

Notifications: Applicant agrees to promptly notify the recipient in writing of any material changes to the information provided.

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