Orem Fast Lube Credit Application
Applicant Information
Name:
Date Birth:						SSN:									Phone:
Current Address:
City:						State:									ZIP:
Own Rent (Please circle)				Monthly payment or rent:													How long?
Previous Address:
City:						State:									ZIP:
Owned Rented (Please circle)					Monthly payment or rent:												How long?
Employment Information
Current Employer:
Employer Address:																	How long?
Phone:				E-mail:										Fax:
City:						State:										ZIP:
Position:			Hourly Salary (Please circle)										Annual Income:
Previous Employer:
Address:																	How long?
Phone:				E-mail:										Fax:
City:						State:										ZIP:
Position:			Hourly Salary (Please circle)										Annual Income:
Name of a relative not residing with you:
Address:
City:									State:			ZIP:					Phone:
Relationship:
Co-Applicant Information, if for a joint account
Name:
Date Birth:						SSN:									Phone:
Current Address:
City:						State:									ZIP:
Own Rent (Please circle)						Monthly payment or rent:											How long?
Previous Address:
City:						State:									ZIP:
Owned Rented (Please circle)						Monthly payment or rent:											How long?
Employment Information
Current Employer:
Employer Address:																	How long?
Phone:				E-mail:										Fax:
City:				State:											ZIP:
Position:			Hourly Salary (Please circle)										Annual Income:
Previous Employer:
Address:
Phone:				E-mail:										Fax:
City:				State:												ZIP:
Position:			Hourly Salary (Please circle)										Annual Income:
Name of a relative not residing with you:
Address:
City:				State:							ZIP:						Phone:
Relationship:
Credit Cards
Name							Account No.			Current Balance									Monthly Payment
Mortgage Company
Account No.:				Address:
Auto Loans
Auto Loans	Account No.							Balance			Monthly Payment
Other Loans, Debts, or Obligations
Description		Account No.														Amount
Other Assets or Sources of Income
Description											Amount per Month or Value
I authorize Orem Fast Lube to verify the information provided on this form as to my credit and employment history.
Signature of Applicant																		Date
Signature of Co-Applicant, if for joint account																		Date