Credit Disclosure Request

Dear

Enclosed is a photocopy of Mr. Smith's signed authorization
for disclosure of credit information.  Would you be kind
enough to supply the information requested below.  We have
provided you with a copy of this request for your files.
Please return the original in the enclosed, postage paid
envelope.

Name of Applicant:  __________________________________
Address:            __________________________________
City, State, Zip:   __________________________________

Length of time of Credit Account:

Highest Credit Extended:

Credit Limit:

Average Monthly Balance:

Balance Now Due:

Balance Past Due:

Normal Paying Habits:

Remarks:

