AMS: Wheelchair Van Rental and Sales
address

CREDIT APPLICATION

Please print this form, complete it, make sure your handwriting is legible, and send it to the address below.

ACCESS MOBILITY SYSTEMS  13011 Highway 99, Everett, WA 98204

***Note: This credit application is valid for Access Mobility Systems only.***

Primary Applicant

 

 

 

 

Last Name

First Name

M.I.

Social Security

 

 

 

 

Date of Birth

Email Address

Home Phone

Cell Phone

 

 

 

 

 

Current Address

City

State

zip code

How Long (yrs)

 

 

 

 

 

Previous Address if less than 2 years at present address

City

State

zip code

How Long (yrs)

 

 

 

 

 

 

Landlord/Mortgage Holder

own home

payment

purchase price

mortgage balance

approx. home value

 

 

 

Occupation

Work Phone

Yearly gross wage/salary

 

 

 

 

 

 

Employer

Address

City

State

zip code

how long (yrs)

 

 

 

Nearest relative not living at my address

Relationship

Phone Number

 

 

 

 

 

Relatives present address

City

State

zip code

how long (yrs)

 

 

 

Other yearly income

Source

Co-Applicant

Bank with savings/checking acct.

 

 

 

 

Last name

First Name

M.I.

Social Security

 

 

 

 

Date of Birth

Email Address

Home Phone

Cell Phone

 

 

 

 

 

Current Address

City

State

zip code

How Long (yrs)

 

 

 

 

 

Previous Address if less than 2 years at present address

City

State

zip code

How Long (yrs)

 

 

 

 

 

 

Landlord/Mortgage Holder

own home

payment

purchase price

mortgage balance

approx. home value

 

 

 

Occupation

Work Phone

Yearly gross wage/salary

 

 

 

 

 

 

Employer

Address

City

State

zip code

how long (yrs)

 

 

 

Nearest relative not living at my address

Relationship

Phone Number

 

 

 

 

 

Relatives present address

City

State

zip code

how long (yrs)

 

 

 

Other yearly income

Source

Bank with savings/checking acct.

I/WE CERTIFY THAT EACH OF THE STATEMENTS MADE AND ANSWERS GIVEN IN THIS CREDIT APPLICATION IS TRUE AND CORRECT AND IS MADE FOR THE PURPOSE OF INDUCING THE FINANCING/LEASING.

I/WE AUTHORIZE THE OBTAINING OF A CONSUMER REPORT TO BE USED IN EVALUATING THIS APPLICATION AND THE OBTAINING AND EXCHANGING OF CREDIT INFORMATION FROM AND WITH OTHER CREDITORS AND CONSUMER REPORTING AGENCIES.

 

 

 

 

Primary applicant signature

Date

Co-applicant signature

Date

 

ACCESS MOBILITY SYSTEMS
13011 Hwy. 99 
Everett, WA 98204 
(425) 353-6563 Fax: (425) 355-6159
 Toll Free: 1-800- 854-4176
e-mail: info@accessams.com

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Want more information on these products? Call us today to speak with or schedule an appointment with a mobility consultant. Call us at (425) 353-6563 or toll free at 1-800-854-4176, contact us online through our contact form, or Email us directly.

AMS offers low cost financing: Online Credit Application.  Or Print a Credit Application

                 Online Store              

For low cost financing call AMS at: 1 800 854 4176

Note: While we try to make sure that all information above is accurate, mistakes may occur in descriptions for which we are not liable. All trademarks used belong to their respective owners, and any trademark is used without permission, and the publication of the trademark is not authorized by, associated with or sponsored by the trademark owner.

last updated May 2010

Copyright 2002 - 2010 Access Mobility Systems