Please select the computer package you are interested in:

Desktop System 1	Desktop System 2	Desktop System 3
Desktop System 4	Desktop System 5	Desktop System 6
Laptop System 1	Laptop System 2	Gaming System 1
Gaming System 2

Personal Information: Applicant (Last,First,Middle)

Email Address: 
Best way to contact me:                 Telephone Email Fax Snail Mail
Social Security Number:  
Date of Birth:                   

Home Address:
City:     
State:   
Zip:      
Home Phone: 
Cell Phone:    
Rent/Own:      RENT OWN
Payment amount:
Car payment amount:     

Name/Address of one relative:
Relatives Phone Number:       
How Related?:                       

How did you find us?:             Internet Search Newspaper Ad PhoneBook

Married/Single?:                     MARRIED SINGLE
If married  you must fill out spouse information.

Credit information: (please remember to fill in all fields)
Individual Credit Joint Credit

Co-applicant information: (Last, First, Middle name)

Social Security Number:   
Date of Birth:                    
Monthly Net Income:        
Employer, (Name, Address, City, State, Zip):

Work Phone:           
Position:                   
Number of Years Employed Here: 


Important Information for All applicants:
Have you ever filed for Bankruptcy?:    YES NO
If yes, was the bankruptcy discharged? YES NO

List all allotments and monthly payment amount and balance:
Creditor Payment Balance:


Additional Information:
I hereby declare I am applying for a sales contract with Military Acceptance Corporation 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 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.

The above statements are true, and I further consent to the release of the pertinentinformation. Applicant Signature_____________________________ Date _________ Co-Applicant Signature_____________________________ Date _________