Puppy Payments Application
1
Purchase
2
Customer
3
Identification
4
Housing
5
Banking
6
Employment
Purchase
Are you a legal citizen of the US or Canada?
*
Yes
No
Estimated Purchase Amount
*
Have you declared bankruptcy in the last 7 years?
*
No
Yes - Discharged
Yes - Open
Bankruptcy year
Bankruptcy State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Reference name (1)
*
Phone (1)
*
Relationship to you (1)
*
Spouse
Child
Parent
Grandparent
Aunt / Uncle
Other Relative
Co-Worker
Friend
Other
Reference name (2)
*
Phone (2)
*
Relationship to you (2)
*
Spouse
Child
Parent
Grandparent
Aunt / Uncle
Other Relative
Co-Worker
Friend
Other
Customer
Name
*
First
Middle
Last
Address
*
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Identification
Date of birth
*
Date Format: MM slash DD slash YYYY
Social security number
*
ID type
*
State Drivers License
Military ID
State ID
ID number
*
ID expiration
*
Date Format: MM slash DD slash YYYY
State Issued
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Mobile phone
*
Home phone
Email
*
Enter Email
Confirm Email
Housing
Rent or own
*
Own Home
Rent
Other
Resident type
House
Apartment
Condominium
Mobile Home
Other
Years at address
*
Please enter a number from
1
to
100
.
Months at address
*
Please enter a number from
1
to
12
.
Property Value
Present Balance
Mortgage Payment
Monthly Rent
Mortgage Holder
Landlord Name
Mortgage Holder's Phone
Landlord Phone
Banking
This is optional but is encouraged as it speeds up the process.
If you do not feel comfortable providing this information, an associate will contact you and ask for this information.
Bank Type
Savings
Checking
Bank Name
Bank Account Number
Bank Routing Number
Card Type
Credit
Debit
Third Choice
Card Number
Card CVV
Card Expiration
Billing Zip Code
Employment
Employer Name
*
Employment Status
*
Employed
Self Employed
Unemployed
Student
Retired
Military
Years With Employer
*
Please enter a number from
1
to
100
.
Months With Employer
*
Please enter a number from
1
to
12
.
Employer Phone
*
Employer Address
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Gross Monthly Income
*
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Comments
This field is for validation purposes and should be left unchanged.
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