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JCPenney Charge Application
NEW YORK RESIDENTS NOTE: We may request a credit report from
a credit bureau to aid us in evaluating your application, or after your
account is opened to update our records, renew your account. or
decide upon the extension of additional credit. Ifyou ask,we'll tell you
if we have requested a report, an'd. if so. we will give you the name
and address of the credit bureau that supplied us with the report.
Signature
Your Signature(s) mean(s)
Applicant's S1gna1ure
that you have read and agree
to the terms of our Retail
Installment Credit
Co-Applicanrs Signature
Agreement (Contract
TheOhio laws against discrimination require that all creditors make credit
equally available to all creditworlhy customers, and that credit reporting
agencies maintain separate credit histories on each individual upon re–
quest. The Ohio Civil Rights Commission administers compliance with
this law.
Date
Date
Type of Account You Want !Check One)
0
lnd1v1dual
Have You Applied for an Account Before?
Applicant
0
Yes
D
No
Q
Jo1n1
Where
When
Co-Applicant
0
Where
When
Yes
Name of Applicant 10 Whom Our Billing StatemenlS Should Be Sent
Social Security Number
Date of
r,1rth
(F
If
St)
(lnil1al)
{LaSI)
Name of Co-Applicant (If Joint Account ReQuested)
(First)
(lnilial)
(Last)
Social Security Number Date of Birth
Name and Refat1onsh1p(s) to Applicant(SJ of Any Other Person (s) You Will Allow to Charge Purchases 10 Your Account
1Firs1)
(Initial)
(Last)
(Rela11onsh1p)
D
No
No of Dependent
Children
Relalionsh1p
10 Applicant
Information about Applicant to Whom Our Billing
I
Information about Co-Applicant
Statements Should Be Sent
(If Joint Account Requested)
Present Residence Address- Street
Present Residence Address-Street
City. Slate
Zip'
l l
I
I
C11y. Slate
For Office Use Only
x·eo
Zip
I
l l l
Area Code
&
Phone Number
I
How Long at this Aadress
I
Monthly Mtge./Rent
Area Code
&
Phone Number
I
How Long at this Address
I
Monthly Mtge./Rent
(
)
Yrs.
Mos.
(
l
Yrs
Mos.
Do You
Do
You
I
D o wn
D
Ren!
D
OwnMob1le
Home
D
L1vew1lh
Parents
D
Other
(Please Speedy)
0
Own
D
Rent
D
OwnMob1le
Home
0
Uvew11h
Parents
0
Other
'
(Please Specify)
Former Address-S1ree1
How Long
Former Address-Streel
How Long
City, State
Zip
I I I
I
I
City. State
Zip
I
I l
Employer's Name (Give Firm's Full Name)
How Long
Employer's Name (Give Firm's Full Name)
How Long
Employer·s Address
I
Business Telephone
Employer's Address
I
Business Telephone
Type of Business
Present Pos111on
Monthly Salary
Type of Business
Present Pos11ion
Monthly Salary
You Need Nol Furnish Alimony. Child Support. or Separate Maintenance Income Information If You
Do
Not Want Us to Consider It 1n Evaluating Your Apphca11on
Other Income-Source (s)
Amount (Monthly)
Other Income-Source (s)
Bank-Branch
1
Bank-Branch
2.
Account 1n the Name of
Account in the Name of
Credit Cards (Include Loan or Finance Companies)
Firm Name
Location
2.
Checking & Savings
D
Checking & Savings
D
Account/ Loan Number
Checking
D
Savings
D
Account/Loan in the Name of
I
Loan
D
366
JCPenney
MAIL APPLICATION to your Distribution Center, c/o New Accounts Dept. See 5 addresses, page 364.