JCPenney
Credit Application
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JAccountNumber
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This application does not apply to Customers whose accounts will be billed by the JCPenney Credit Office in Puerto Rico.
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GENERAL INFORMATION (Please Print All Information) An Applicant, If Married, May Apply for a Separate Account.
Type of Account You Want
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Social Securrty Number
0
Individual
Name ofApplicant To Whom Our Billing Statements Should Be Sent (First, Middle Initial,Last)
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0
Joint
No. of
Dependent
Children
0
None
0
One
0
Two
0
Three
0
Four or More
Name of Co-Applicant, If Joint Account Requested (First, Middle Initial, Last)
Name and Address of Non-Applicant Spouse (In Wisconsin Only)
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Social Security Number
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Date
o~Birth
/
!
Name of Any Other Person(s) You Will Allow To Charge Purchases
To Your Account {First. Middle Initial,Last)
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INFORMATION ABOUT APPLICANT TO WHOM OUR BILLING STATEMENTS SHOULD BE SENT
Present Address -
Street
Apt.
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City,
State
Area Code
&
Phone Number
Relationship To Applicant
0
Spouse
Relationship To Applicant
0
Spouse
0
Other
0
Other
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Monthly Mtge./Rent
/
Do you
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Own
0
Rent
0
Own Mobile Home
0
live With Parents
0
Other (Please Specify)
How Long at This Address
0
0·6mos.
D
7mos.-
1yr.6mos.
D
1
yr.
7 mos.-
2yrs. 6 mos.
Former Address (If At Current Address
Less Than Two
Years)-Street
Apt.
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ADDITIONAL INFORMATION ABOUT APPLICANT
Employer (Give
Firm's
Full Name)
Employer's Address (Street, City, State)
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~siness
Te;epoone
How Long
0
0
0-6
mos.
2yrs. 1mo.-
0
4yrs. 6mos.
Type
ol
Business
0
7mos.-
1
yr.
4yrs. ?mos.-
0
6yrs. 6mos.
0
1yr.1 mo.-
2 yrs.
6yrs.7mos.-
0
1
O
yrs. 6 mos.
1
O
yrs. 7 mos.
or More
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Monthly Salary
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Present Position
0
City,
State
2yrs. ?mos.-
0
5yrs. 6mos.
5yrs. ?mos.-
0
8
yrs. 6mos.
Byrs. ?mos.-
0
15 yrs. 6 mos.
15 yrs. 7 mos.
or More
12lp
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/HowLoog
INFORMATION ABOUT CO-APPLICANT (If Joint Account Requested)
Employer
(Give
Firm's
Full
Name)
Employer's Address (Street. City, State)
HowLong
0
0
0-6
mos.
2yrs. 1 mo.-
0
4yrs."6 mos.
Type of
Business
0
7mos.-
1
yr.
4yrs. ?mos.-
0
6yrs. 6mos.
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Monthly Salary
0
1yr. 1 mo.-
2 yrs.
6yrs. ?mos.-
0
1
O
yrs. 6 mos.
1
O
yrs. 7 mos.
or More
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Present Position
You Need Not Furnish Alimony, Child Support or Separate Maintenance Income Information
If
You Do Not Want Us To Consider It In Evaluating Your Application.
Other
Income - Source{s)
Amount (Monthly)
Other
Income- Source(s)
Amount (Monthly)
BANK ACCOUNTS (Include Co-Applicant's, If Joint Account Requested)
Bank-Branch
Account
in
the
Name
of
Account Number
D
Checking and
Savings/NOW Acct.
0
Checking
0
Savings/CD
0
Loan
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LIST ALL CREDIT REFERENCES (Include Co-Applicant's, If Joint Account Requested) - Credit Cards (Include Loan or Finance Companies)
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MasterCardNisa
0
AMEX/Diners
0
Department Store
0
Other Credit References (List Below)
Firm Name
Location
AccounVLoan Number
AccounVLoan in the Name of
'
1.
'
2.
.
'
"·
•.
3.
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PERSONAL REFERENCE
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Name of Nearest Relative Not Living at
Address
of Applicant or Co-Applicant
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Relationship To Applicant
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Present Address (Street. City, State)
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~ea
Code ; Poone Number
Sign here to complete your JCPenney Credit Application.
Your Signature(s) mean(s) that you have read, understood, and agree to the terms of the above Retail Installment Credit Agreement.
Applicant's
Signature
Date
Co-Applicant's
Signature
Date
K20
JCPenney
381