Hotel Pharmacy Application for Credit
Applicant Name:  ____________________________________	Social Security #:  _________________________
Co-Applicant Name:  _________________________________	Social Security #:  _________________________
Address: ____________________________________________________________
Address: ____________________________________________________________
How long at this address: ______________________________
Applicant Home Phone: _____________________	Work Phone: _____________________
Co-Applicant Home Phone: _____________________	Work Phone: _____________________
Place of Employment:
Applicant: ____________________________	How Long: ____________
Co-Applicant: ___________________________	How Long: ____________
Local Charge Accounts: (Name, address, phone, & account #)
1. _________________________________________________________________________
2. _________________________________________________________________________
3. _________________________________________________________________________
Other Charge Accounts/Credit Cards: (Name, address, phone, & account #)
1. _________________________________________________________________________
2. _________________________________________________________________________
Bank Information:
Name: ___________________________________________________________________
Address & Phone: _________________________________________________________
Account Type & Number: ___________________________________________________
Personal References: (Name, address, phone)
1. _________________________________________________________________________
2. _________________________________________________________________________
I give my permission for Hotel Pharmacy to receive credit information from the sources listed above, and to verify employment. I understand that my bill will be due upon receipt, and that 1 ½% interest per month (18% per year) will be charged on any balance 30 days past due, with a minimum charge of $.50, and I agree to pay all finance charges added to an overdue acount. Charge privileges will be suspended on any account with a 60-day or more past due balance, or at any other time at the discretion of Hotel Pharmacy employees.

Applicant Signature: ______________________________	Date: ___________________
Co-Applicant Signature: ____________________________	Date: ___________________