Personal Data

Name (last, first, middle) __________________________________________________________________________________

Social Security Number               -             -            Birthdate _____/_____/______ Number of Dependent/Ages________

Mailing Address_____________________________________   City ______________    State ____    Zip______     Years_____

Physical Address ____________________________________     City ______________    State ____    Zip______     Years_____

Home Phone (       )_______________________________          Work Phone (       )___________________________

Have you ever delcared Bankruptcy? ____________ Had a Repossession? ___________ Judgement?___________

Email Address _______________________________________________________

Registered in which Shooting Association?_______________________ Membership #________________________

Driver's License Number_____________________________________________        State________________

Employment History

Employer_____________________________________________            Years at this Company____________________

Address_______________________________________       City______________     State__________     Zip________

Phone (       )________________________       Title_____________________      Salary/Wages(Gross)______________

Previous Employer______________________________________           Years at this Company____________________

Address_______________________________________       City______________     State__________      Zip________

Personal and Credit References

Personal Reference:      Name_______________________________________ Relationship_______________________

Address____________________________  City___________________   State___________     Zip_______________

Name of Creditor/Credit Card_______________________________ Account Number___________________________

Address/Branch___________________________________________________________________________________

Date Opened__________________________ Balance__________________ Monthly Payment__________________

 
I certify that the statements herein are true and that I am not liable for any debts, other than specifically listed. Europa Corporation, d.b.a. duPONT/KRIEGHOFF is authorized to obtain any information which it deems necessary for consideration of the credit request and during the credit transaction, if approved.

Signature (Youth Shooter) ________________________________________________________________ Date_____________

Co-Signature (Parent/Guardian) ___________________________________________________________ Date_____________