Fields marked with a * are required

APPLICANT

General Information
*First Name:
*Middle Initial:
*Last Name:
*Birth Date:
*Email:
*Day Phone:
*Evening Phone:
*Number of Dependents:
*Nearest Relative:
*Relationship:
*Relative's Phone:
*Relative's Address:
*Relative's City:
*Relative's State:
*Relative's Zip:
*Have You Ever Filed Bankruptcy? Yes
No
Will there be a Co-applicant? Yes
No
Residency Information

Please provide a 5 year residency history

*I am currently: Owning a home
Buying a home
Living with relatives
Leasing/Renting
Owning/Buying a mobile home
Residence 1
*Current Home Address:
*City:
*State:
*Zip:
*House Payment/Mo:
Year Purchased:
Price Paid:
*Years at current home:
Residence 2
Previous Address:
City:
State:
Zip:
Number of years at previous home:
Residence 3
Previous Address:
City:
State:
Zip:
Number of years at previous home:
Employment History

Please provide a 2-year employment history

Employer 1
*Current Employer:
*Position:
*Employer's Address:
*Employer's City:
*Employer's State:
*Employer's Zip:
*Employer Phone #:
*How long have you been employed here?
*Gross Income/Mo:
Employer 2
Previous Employer:
Position:
Time with:
Employer Phone #:
Gross Income/Mo:
Employer 3
Previous Employer:
Position:
Time with:
Employer Phone #:
Gross Income/Mo:

CO APPLICANT

General Information
*First Name:
*Middle Initial:
*Last Name:
*Birth Date:
*Email:
*Day Phone:
*Evening Phone:
*Number of Dependents:
*Nearest Relative:
*Relationship:
*Relative's Phone:
*Relative's Address:
*Relative's City:
*Relative's State:
*Relative's Zip:
*Have You Ever Filed Bankruptcy? Yes
No
Residency Information

Please provide a 5 year residency history

*Is this residency information the same as the applicant information? Yes
No
*I am currently: Owning a home
Buying a home
Living with relatives
Leasing/Renting
Owning/Buying a mobile home
Residence 1
*Current Home Address:
*City:
*State:
*Zip:
*House Payment/Mo:
Year Purchased:
Price Paid:
*Years at current home:
Residence 2
Residence2 Address:
City:
State:
Zip:
Number of years at previous home:
Residence 3
Residence3 Address:
City:
State:
Zip:
Number of years at previous home:
Employment History

Please provide a 2-year employment history

Employer 1
*Current Employer:
*Position:
*Employer's Address:
*Employer's City:
*Employer's State:
*Employer's Zip:
*Time with:
*Employer Phone #:
*Gross Income/Mo:
Employer 2
Previous Employer:
Position:
Time with:
Employer Phone #:
Gross Income/Mo:
Employer 3
Previous Employer:
Position:
Time with:
Employer Phone #:
Gross Income/Mo:

By submitting this form, you agree to Jayco's privacy policy and accept any contact from your local dealer regarding your secure credit application. This application does not collect your social security number for your protection, however, your dealer may request it to complete your credit application.