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?*
Estimated Purchase Amount*
Have you declared bankruptcy in the last 7 years?*
Bankruptcy year
Bankruptcy State
Reference name (1)*
Phone (1)*
Relationship to you (1)*
Reference name (2)*
Phone (2)*
Relationship to you (2)*

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*
ID number*
ID expiration*
Date Format: MM slash DD slash YYYY
State Issued*
Mobile phone*
Home phone
Email*
Enter Email Confirm Email

Housing
Rent or own*
Resident type
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
Bank Name
Bank Account Number
Bank Routing Number
Card Type
Card Number
Card CVV
Card Expiration
Billing Zip Code

Employment
Employer Name*
Employment Status*
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*
CAPTCHA
Comments
This field is for validation purposes and should be left unchanged.