Long Credit - Affordable Furniture

1Choose the Type of Account Application

Type of Application (Check One):

Individual
Joint

Credit Check
No Credit Check

* Field is required.

2Individual Applicant Information

First Name:*

Middle Initial:*

Last Name:*

Date of Birth:*

Social Security:*

Language:

Driver's License #:*

Driver's License State:*

Driver's License Expiration Date:

Home Phone:*

Cell Phone:

Carrier:

Email Address:*

Billing Address is the same as the Mailing Address Billing Address is the same as the Mailing Address:

Owns Home:*

Own Home

Rents
Owns/Buying

Monthly Payment:

Mortgage / LandLord:

Street Address:*

Apt. or Suite:

Mortgage / LandLord Phone:

City:*

State:*

Postal Code:*

2aCo-Applicant Information

First Name:*

Middle Initial:*

Last Name:*

Date of Birth:*

Social Security:*

Language:

Driver's License #:*

Driver's License State:*

Driver's License Expiration Date:

Home Phone:*

Cell Phone:

Carrier:

Email Address:*

Owns Home:*

Rents
Owns/Buying

Monthly Payment:

Mortgage / LandLord:

Street Address:*

Apt. or Suite:

Mortgage / LandLord Phone:

City:*

State:*

Postal Code:*

3Individual Applicant Employer Information

Monthly Income:*

Income Type:*

How are you Paid:

Last Pay Date:*

Next Pay Date:*

Employer Name:*

Job Title:*

Hire Date:*

Employer Phone:

Employer Street Address:

Employer Apt/Suite:

Employer City:*

Employer State:*

Employer Postal Code:*

3aCo Applicant Employer Information

Monthly Income:

Income Type:*

How are you Paid:

Last Pay Date:*

Next Pay Date:*

Employer Name:*

Job Title:*

Hire Date:*

Employer Phone:

Employer Street Address:*

Employer Apt/Suite:

Employer City:*

Employer State:*

Employer Postal Code:*

4Individual Applicant Bank Information

Bank Name:*

Account Open Date:*

Account Type:*

Account Number:*

Routing Number:*

5Individual Applicant References

Reference 1 Name:*

Phone:Reference1*

Relationship:Reference1*

Reference 2 Name:*

Phone:Reference2*

Relationship:Reference2*

Reference 3 Name:*

Phone:Reference3*

Relationship:Reference3*

Has Applicant (Co-Applicant) ever declared Bankruptcy?:*

Has Applicant (Co-Applicant) ever declared Bankruptcy?

6Previous Store Credit

Has Applicant (Co-Applicant) ever been extended credit through any Affordable Furniture - Houston Store?':*

Has Applicant (Co-Applicant) ever been extended credit through any Cheap Furniture Direct Test Store?

If Yes, Which Store?

Store:*

7Disclaimer and Signature

By clicking "SUBMIT", I acknowledge that I am signing this Application electronically, and that my electronic signature is the legal equivalent of my written signature on the Application. I consent to be bound by the terms and conditions and important disclosures of the Application. I further understand that I am requesting that Affordable Furniture Texas (and its subsidiaries) enter a Lease-Purchase agreement with me.

I hereby: (1) certify that all information I have provided or will provide is true, correct, and complete; (2) Consent to receive the disclosures contained in the Application electronically; (3) consent to Affordable Furniture Texas contacting any person or company listed on my application to obtain information about me and fully release all parties from any claim that may arise out of such contact; (4) authorize Affordable Furniture Texas to charge any credit or debit card (as described in the Application) in the amount of my Initial Payment if my application is approved and I execute a Lease-Purchase agreement with Affordable Furniture Texas authorizing such a charge; (5) agree that Affordable Furniture Texas may obtain one or more consumer reports ("Consumer Reports") in connection with either (a) my application, (b) any updates, renewals, or extensions of any transaction resulting from my application ("Transactions"), (c) the review or collection of any Transaction and (d) other legitimate business purposes related to any Transaction; (6) understand that upon my request (a) I will be informed whether Affordable Furniture Texas obtained Consumer Reports and, if so, the name and address of the individual or company that furnished the Consumer Reports; (7) authorize Affordable Furniture Texas to share information with the merchant whose goods I am interested in leasing ("Dealer") about Affordable Furniture Texas 's decision to offer me a rent-to-own transaction, and authorize Affordable Furniture Texas to share my application information and lease terms with Dealer; and understand that I can withdraw my consent by closing this web session without submitting my application.

Name of Spouse :

Address of Spouse :

Signature of Applicant : *(By typing your name in this box, you are Legally signing this Document)

Signature of CO-Applicant : *(By typing your name in this box, you are Legally signing this Document)

8Select the Closest Store to Your Location

Send to Store: *

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Please Print this Form out for your Own records*:

By clicking on the submit button, you have read, understood and accepted the terms in section 9 above:

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