MYPAY CREDIT STORE APPLICATION
If you have a Promo Code Please Enter Here:

Is this an individual or joint application? 
Select Employer or Service
......... 
 Select Type of Product
Item # or description of product request 
* Last Name
* First Name
M.I.
* Email Address
* Social Security #
... 
* Date of Birth
* Present Home Address
* City
* State
* Zip
(Military only)
Base or Installation
(Military only)
Rank
.... 
(Military only)
Branch
(Military only)
Permamnent Home of Record City, State, Zip
(Military only)
Date Entered
.......... 
(Military only)
ETS/EOAS/EAS/
Employer
Yrs. Employed
Employers Address
Job Description
Home Phone
Work Phone (or Unit Phone)
Pay Grade
...... 
Pay step
  
Monthly Income (Gross)
Living Situation
Amount
Car Payment 1
Car Payment 2
Marital Status
Retired?
Number of Children
Ever filed for bankruptcy?
Was bankruptcy discharged?
Please list all allotments
* * * Co-Applicant Information * * *
* * Complete spaces below if this is a joint application * * 
Co-Applicant Last Name
First Name
M.I.
Birth Date
Social Security #
..... 
Monthly Income (Gross)
Employer
Address (City, State, Zip)
Yrs. Employed
* * Special Offer for All Applicants! * *
Save up to $50 off the purchase of your product by referring us to your friends! Here's how it works:
For each email address of your active duty friends that you enter into the form below, we will deduct
$10 off the purchase price of your loan.  
Friend Email 1:
Friend Email 2:
Friend Email 3:
Friend Email 4:
Friend Email 5:
Examples:
1 address= $10 off
2 addresses= $20 off
3 addresses= $30 off
4 addresses= $40 off
5 addresses= $50 off 

Additional Information:

I hereby declare I am applying for a sales contract with US Credit Sales Inc. and/or one of it’s partners, affiliates, or brokers/dealers under the provision of Section 552a(b) Public Law 93-579, commonly known as the Privacy Act, Dept. of Defense 5400.11 enc 5 Par3 - 2 apr 340 - 21 Dept. of the Army, 27 August 1975 Section C, Par 24 AFR 12-35, Dept. of the Air Force Par 7a(1), SECNABINST 5211.5 Dept. of the Navy 14 August 1975. I understand that my application may be submitted to one or more lenders, partners, affiliates, or brokers/dealers to obtain suitable financing for said contract. I further understand that the Lender will not contact my Commanding Officer in connection with this debt unless I specifically give the Lender prior consent to make such contact. With full knowledge and understanding of this right, I hereby consent to contacting my Commanding Officer/Personnel Officer and/or Custodian of my official records to obtain my current military and /or civilian address even though I may be discharged and/or retired from military service. I also consent to you contacting my Commanding Officer in connection with the collection of the debt made hereby at any time when it is in default and until such time as the debt has been paid in full.
 I have read the above terms and I agree to them
 

The above statements are true, and I further consent to the release of the pertinent information.
If you are printing this, please sign below.

Applicant
Signature_____________________________

Date _________

Co-Applicant
Signature_____________________________

Date _________
 

Attention!  In order to complete the Application Process you must fax a copy of your LES to the one of the numbers below:


Call toll-free
800-635-6268


Fax: 770-640-6752

* Indicates Response Required