Douglas James Application – Client Financing

Personal Information

First Name(Required)

Middle Name

Last Name(Required)

Address(Required)

City(Required)

State(Required)

Zip Code(Required)

Own or Rent(Required)

Time At Address(Required)

*Time shown in years. If 0-11 months, select 0 yrs.

Housing Payment(Required)

DOB(Required)

SSN(Required)

Phone Number(Required)

EXAMPLE: 5551113434 (No Dashes)

Email Address(Required)

Income/Employment Information

Employer Name(Required)

If you are self employed, list "self employed" as the Employer.

Occupation / Title(Required)

What is your job title or the industry you work in?

Phone Number(Required)

EXAMPLE: 5551113434 (No Dashes)

Length of Employment(Required)

Employer Address(Required)

City(Required)

State(Required)

Example: WY

Zip Code(Required)

Average Income(Required)

Income Period(Required)

How often are you paid?

Payment Information

We collect two (2) forms of payment; Credit/Debit Card & ACH.

Bank Name

Account Number

Routing Number

Account Type

Payment Information (Card)

We collect two (2) forms of payment; Credit/Debit Card & ACH.

Card Number

Card Brand

Month(Required)

Year(Required)

CVV(Required)

Two References

Please provide two references. They will be no outreach to the references provided unless the customer defaults on payments and avoids all collection efforts.

Reference #1

First Name(Required)

Last Name(Required)

Phone Number(Required)

EXAMPLE: 5551113434 (No Dashes)

Relationship(Required)

Reference #2

First Name(Required)

Last Name(Required)

Phone Number(Required)

EXAMPLE: 5551113434 (No Dashes)

Relationship(Required)