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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

/

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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

0

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)

0

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

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