1Choose the Type of Account Application

Type of Application (Check One):

Individual
Joint

Credit Check
No Credit Check

* Field is required.

2Individual Applicant Information

First Name:*

Middle Initial:*

Last Name:*

Date of Birth:*

Social Security:*

Language:

Driver's License #:*

Driver's License State:*

Driver's License Expiration Date:

Home Phone:*

Cell Phone:

Carrier:

Email Address:*

Billing Address is the same as the Mailing Address:

Owns Home:*

Rents
Owns/Buying

Monthly Payment:

Mortgage / LandLord:

Street Address:*

Apt. or Suite:

Mortgage / LandLord Phone:

City:*

State:*

Postal Code:*

2aCo-Applicant Information

First Name:*

Middle Initial:*

Last Name:*

Date of Birth:*

Social Security:*

Language:

Driver's License #:*

Driver's License State:*

Driver's License Expiration Date:

Home Phone:*

Cell Phone:

Carrier:

Email Address:*

Owns Home:*

Rents
Owns/Buying

Monthly Payment:

Mortgage / LandLord:

Street Address:*

Apt. or Suite:

Mortgage / LandLord Phone:

City:*

State:*

Postal Code:*

3Individual Applicant Employer Information

Monthly Income:*

Income Type:*

How are you Paid:

Last Pay Date:*

Next Pay Date:*

Employer Name:*

Job Title:*

Hire Date:*

Employer Phone:

Employer Street Address:

Employer Apt/Suite:

Employer City:*

Employer State:*

Employer Postal Code:*

3aCo Applicant Employer Information

Monthly Income:

Income Type:*

How are you Paid:

Last Pay Date:*

Next Pay Date:*

Employer Name:*

Job Title:*

Hire Date:*

Employer Phone:

Employer Street Address:*

Employer Apt/Suite:

Employer City:*

Employer State:*

Employer Postal Code:*

4Individual Applicant Bank Information

Bank Name:*

Account Open Date:*

Account Type:*

Account Number:*

Routing Number:*

Cardholder's Name:*

Credit Card Number:*

Expiration Date:*

CVV Number:*

5Individual Applicant References

Reference 1 Name:*

Phone:*

Relationship:*

Reference 2 Name:*

Phone:*

Relationship:*

Reference 3 Name:*

Phone:*

Relationship:*

Has Applicant (Co-Applicant) ever declared Bankruptcy?:*

6Previous Store Credit

Has Applicant (Co-Applicant) ever been extended credit through any Brian's Furniture - Corbin, KY Store?');?>:*

If Yes, Which Store?

Store:*

7Disclaimer and Signature

Name of Spouse :

Address of Spouse :

Signature of Applicant : * (By typing your name in this box, you are Legally signing this Document)

Signature of CO-Applicant : * (By typing your name in this box, you are Legally signing this Document)

8Select the Closest Store to Your Location

Send to Store: *

Please Print this Form out for your Own records*:

By clicking on the submit button, you have read, understood and accepted the terms in section 9 above: