Credit Application

First Name

Last Name

Address

City

State

Zip

Email Address

Primary Phone

Secondary Phone

Social Security Number

Date of Birth

Drivers License Number/ID

Drivers License Issue Date

License Expiration Date

License Issue State

Employment Status

Current Employer

Employer Phone

Occupation

Start Date (MM/DD/YYYY)

Gross Monthly Income

Residence Type

Monthly Mortgage/Rent Payment

Time at Current Residence

Alkagem partners with multiple financing lenders to provide customers with the best rates and options available based on each individual’s credit factors. Please note that financing fees, APR percentages, transaction fees, and interest rates may vary based on your credit history and financing programs available. Alkagem and it’s financing partners will disclose any and all associated financing fees, APR percentages, transaction fees and interest rates as required by law before any order is processed. You must be 18 years of age or older in order to apply for financing with any of Alkagem’s financing partners. By submitting this form, applicant provides written consent under the Fair Credit Reporting Act for merchant and lenders and partners with whom merchant is matched with to obtain consumer reporting information from consumers credit profile or other information from one or more credit bureaus. Customer understands and agrees that Merchant is submitting an application for credit, and are consenting to the use of their consumer report information by merchant and our lenders and partners to conduct anti-fraud security checks and evaluate Customers application for credit. Customer understands that their application may be matched with multiple lenders, each of whom may obtain consumer report information from their credit profile. Due to lender policies, the person who is receiving the services is required to be listed as the main applicant. If you believe the person who is receiving the services has non-qualifying credit, an option to add a co-applicant is provided at the end of this application. Funding may be cancelled or declined if the information provided is not truthful and accurate to the person's best knowledge. Alkagem partners with multiple financing lenders to provide customers with the best rates and options available based on each individual’s credit factors. Please note that financing fees, APR percentages, transaction fees, and interest rates may vary based on your credit history and financing programs available. Alkagem and it’s financing partners will disclose any and all associated financing fees, APR percentages, transaction fees and interest rates as required by law before any order is processed. You must be 18 years of age or older in order to apply for financing with any of Alkagem’s financing partners. By submitting this form, applicant provides written consent under the Fair Credit Reporting Act for merchant and lenders and partners with whom merchant is matched with to obtain consumer reporting information from consumers credit profile or other information from one or more credit bureaus. Customer understands and agrees that Merchant is submitting an application for credit, and are consenting to the use of their consumer report information by merchant and our lenders and partners to conduct anti-fraud security checks and evaluate Customers application for credit. Customer understands that their application may be matched with multiple lenders, each of whom may obtain consumer report information from their credit profile. Due to lender policies, the person who is receiving the services is required to be listed as the main applicant. If you believe the person who is receiving the services has non-qualifying credit, an option to add a co-applicant is provided at the end of this application. Funding may be cancelled or declined if the information provided is not truthful and accurate to the person's best knowledge. Yes, I agree to the above terms.