* First name :

* Last name :

* Address :

* City :

* State : * Zip code :

Select one : Select one Own Rent With Parents Misc

How long : years months

* Social Security # : format : XXX-XX-XXXX      

ID # / Exp :

Employer :

City :

How long : years months

* Monthly income :

You need not include income from alimony, child support, or separate maintenance
unless you are relying on it for repayment of this obligation.

* E-mail :

Phone (home) :

(weekdays) : (mobile) :

Terms/Condition : By marking the box below, I certify that the information provided above is true and
complete. I authorize Encanto Fine Jewelry to obtain credit reports and other information
to evaluate this credit application