Creditability and Reputation_________________________________

How long have you worked with him?___________________________

Highest credit on: Charge account___________________________

Highest credit on: Installment credit_______________________

Present amount owed: Due now________________________________

Present amount owed: Past due_______________________________

Meeting obligations promptly?________________________________

Present Address______________________________________________

Remarks______________________________________________________

Signed________________________ Date________________________

Length of time known?______________________ Age______________

Single or married__________________________

Character________________ Community Reputation_______________

Occcupation______________ Employer's Name____________________

Employment steady?_______ Monthly Income (estimate)$_________

Amount owed you: Due now$_______________ Past due$__________

Meeting obligations promptly?________________________________

Present Address______________________________________________

Remarks______________________________________________________