MyAtlas - Submit Form

APPLICANT INFORMATION(*) REQUIRED FIELD

Salutation: Mr. Mrs. Ms.

First Name:

Last Name:

Date of Birth:

Address:

City:

State:

Zip Code:

How Long (years):

How Long (months):

Housing Type: Own Rent Other

Explain Other:

Marital Status:

Social Security #:

Citizenship: U.S. citizen Permanent resident alien

Visa Exp.

DL Number:

DL State:

Primary Phone Type: Cell Home Work

Primary Phone:

Secondary Phone Type: Cell Home Work

Secondary Phone:

Emergency Phone:

Email:

In the last 6 months, have you lived in a previous address?:

Employment Information

Add Another

Remove Item

Start Date (mm/yyyy):

End Date (mm/yyyy):

if currently employed, then enter this month

Employer Name:

Employer ID Number:

Address:

City:

State:

Zip:

Title:

Supervisor:

Phone:

Add Another

FINANCIAL INFORMATION

Account Type: Checking Saving

Bank Name:

Balance:

Bank Routing Number:

Bank Acct Number:

Checking Date Opened:

Card Type: Credit Debit Card

Card Number:

Exp Date:

CVV2:

Zip Code:

Mo.Gross Income:

Additional Income:

Total Income:

Monthly Housing Expense:

Source of Additional Income:

REFERENCES

First Reference

Name:

Reference Type:

Contact:

Email:

City:

State:

Second Reference

Name:

Reference Type:

Contact:

Email:

City:

State:

Third Reference

Name:

Reference Type:

Contact:

Email:

City:

State:

Fourth Reference

Name:

Reference Type:

Contact:

Email:

City:

State:

SIGNATURE

I hereby acknowledge that I am over the age of eighteen (18) years, and that all information set forth in this credit application is true, accurate, and a full and complete disclosure thereof. I authorize Atlas Financial Group LLC, its Representative, Agent, or Assignee to gather whatever credit information is deemed necessary for approval and to provide such information to financial institutions or others in connection with this credit request, and I understand this application will be retained whether or not it is approved. I further acknowledge and agree I will notify the creditor or prospective creditor, in writing, of any change in my name, address, or employment within a reasonable time thereafter. Any false, erroneous, and/or misleading information provided in this Credit Application or Enrollment/Installment Agreement will be cause for immediate cancellation of any financing arrangements and/or termination of my enrollment.

Borrower's Signature:

IP Address is Tracked for Electronic Signature 18.97.14.89

Date:

Prove you’re not a robot:

STUDENT APPLICATION

APPLICANT INFORMATION(*) REQUIRED FIELD

SPOUSE INFORMATION (Complete if Spouse provides Additional Income)

Employment Information

FINANCIAL INFORMATION

REFERENCES

SIGNATURE