Request for Credit Info on New Account


Enclosed is a photocopy of Mr. Smith’s signed authorization
for disclosure of credit information. Would you be kind
enough to supply the information requested below. We have
provided you with a copy of this request for your files.
Please return the original in the enclosed, postage paid

Name of Applicant: __________________________________
Address: __________________________________
City, State, Zip: __________________________________

Length of time of Credit Account:

Highest Credit Extended:

Credit Limit:

Average Monthly Balance:

Balance Now Due:

Balance Past Due:

Normal Paying Habits:


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