Please answer/fill & check any box show below and click the SUBMIT button at the bottom of the screen to send me your application for monthly financing.

Put the page & item number or numbers of the item or items you want financed in this box.:*
Put Your Full Name (include any suffix) Sr. Jr. III: *
Address: *
City, State & Zip: *
Phone(s) Cell & Home. If you have a home phone include that number.: *
Email: *
Your social security & Drivers License numbers. NOTE: These are not used to do a credit check.: *
Relative #1 Contact Information: Name, Address, City, State, Zip, Phone:*
Relative #2 Contact Information: Name, Address, City, State, Zip, Phone:*
Friend Contact Information: Name, Address, City, State, Zip, Phone:*
Years & Months on your current job.
Years & months at your current address.:
Are you renting?
Answer yes or no.:
Are you buying a home?
Answer yes or no.:
Job Information: Job Name, Address, Phone #, City, State, Zip, Manager or Supervisors name.:*
Bank or Credit Union Information
Include the Name, Address, City, State, Zip & Phone #.:
Collateral List: These items are to be sold if I default on my contract for monthly financing with Michael's Jewelry and all money made from the sell of listed items shall be paid to Michael's Jewelry as payment in full. Give me an estimated amount of what you believe it would take to replace all these items listed. Items listed must have a total dollar amount close to the balance owed if they have to be sold. I agree to this as a condition for getting monthly financing through Michael's Jewelry. List at least 5 to 10 items. (Example: Tv's, car(s), computers, furniture, etc..:*
Put In The Monthly Payment Due Date You Would Like.: *
Terms For Monthly Financing and a copy of your Ordering & Financing Form will be presented to you when I come to take your order as well as having you signing it for monthly financing. Check if you agree to this.
Divided Down Payment Option. Check if you would like to use this option for making your down payment. Explained in person when you check this option and sign your Ordering & Financing Form in person.

(Fields marked with * are required)

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