Simply print this form, fill it out, and fax it or bring it with you to AMDS.
Consumer Credit Application
Alaska Mining & Diving Supply 3222 Commercial Drive Anchorage, Alaska 99501
Phone 907-277-1741 Fax 907-258-3161 email firstname.lastname@example.org
Name (First, Middle, Last) Item to Finance/Finance Amount
Mailing Address (Street or Box, City, State, Zip Code) How Long?
Physical Address (Street, City, State, Zip Code) How Long?
Home Phone Work Phone
Date of Birth
Social Security Number
Driver License Number/State
Current Employer/Position or Grade
Length of Employment
Monthly Gross Salary
Relative NOT Living With You - Name and Phone
Bank Name and Location
|Own Rent Other (Circle One)||____________________|
Rent/Payment per Month
|The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin or sex, marital status, age (provided that the applicant has the capacity to enter into a binding contract); because all or part of the applicantís income derives from any public assistance program: or because the applicant has in good faith exercised any right under the Consumer Protection Act. The Federal agency that administers compliance with this law concerning this creditor is the Federal Deposit Insurance Corporation Regional Director, 25 Eckert Street, Suite 2300, San Francisco, California 94105.|
|TO HELP the government fight the funding of terrorism, money laundering activities, and various forms of fraud, such as identity theft, Federal law requires financial institutions to obtain, verify, and record information that identifies each person that opens an account. We may ask to see your driverís license or other identifying documents.|