LUTHERCREDIT APPLICATION FORM

To help the government fight the funding of terrorism and money laundering activities, Federal law requires financial institutions to obtain, verify and record information that identifies each person who opens an account. What this means for you; When you fill out an application, we will ask you for your name, address, date of birth and other information that will allow us to identify you. We may also ask to see your driverís license or other identifying documents. PATRIOT (8/03)

User Name:
Email:   Why?
Password:
Confirm Password:
First Name:
Middle Initial: Optional
Last Name:
Address:
Apt#:
City:
State:
Zip Code:
Do You: Own Rent Other
Monthly Housing Payment: $ .OO
Phone Number:
Daytime Phone Number:
Social Security Number:   Why?
Date of Birth:
(mm/dd/yyyy)
Why?
Driver's License or
State ID Number:
Why?
State of Issue:
Employment Status:
Employer's Name:
Employer's Phone:
Date of Hire:
(mm/dd/yyyy)
Annual Salary: $ .OO
Do You Have a Checking Account? Yes No
Do You Have a Savings Account? Yes No
Click here if you would like to set up a Joint Account Co-Applicant

RETAIL INSTALLMENT CREDIT AGREEMENT

Click here to read the terms and conditions (PDF Format)

I further understand that by agreeing to these terms, I will allow LutherSales to market to me electronically via email. By unclicking this box, I am stating that I do not wish to receive marketing material electronically via email.

I have read all of the above and agree to these terms and conditions. I understand that the agreement is binding upon approval of the Luther Charge account.

All terms and conditions are subject to final approval.

To electronically sign your application, please type the text below into the box as it appears.

Signature:
(case sensitive)
Suggestion: double click on the signature code above, right click to copy and paste into signature box

How did you hear about us?
Luther Representative:
All Other Inquiries Click Here.



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