MEKKELSEN RV   

P.O. BOX 109

East Montpelier, VT 05651

ATTN: CASEY, Business Manager

PHONE:802-223-3684

FAX: 802-229-6139

Check Appropriate Box - We acknowledge that we are applying for Joint Credit:   Applicant  Yes  No             Co-Applicant Yes  No

                                                                                                                                                             (if there is no co-applicant then click "no")
Applicant Co-Applicant
Social Sec.-- Social Sec. -- 
Date of Birth // Date of Birth //
Last FirstMiddle Last FirstMiddle
Physical Street Address Yrs here Physical Street Address Yrs here
City State Zip City State Zip
E-Mail Address   
Home Phone          Home Phone
Previous Address Yrs there Previous Address Yrs there
Current Employer          Current Employer
Work Phone          Yrs here Work Phone Yrs here
Income Weekly:  Bi-Weekly:  Yearly: Income Weekly:  Bi-Weekly:  Yearly:
Add'l Income Source   Add'l Income Source  
Income Weekly:  Bi-Weekly:  Yearly: Income Weekly:  Bi-Weekly:  Yearly:
Financial Institution(s) for Checking  Financial Institution(s) for Checking 
Financial Institution(s) for Savings Financial Institution(s) for Savings
Mortgage:  Own:  Rent:  Monthly Pmt Mortgage:  Own:  Rent:  Monthly Pmt
Mortgage Holder Mortgage Balance Mortgage Holder Mortgage Balance

 (List at least 1)

  
CreditorMthly PmtBalance Creditor Mthly Pmt Balance
CreditorMthly PmtBalance Creditor Mthly Pmt Balance
CreditorMthly PmtBalance Creditor Mthly Pmt Balance

_________________________________________________________________________________
Unit Information |  New:   Used:  |   Stock # (if applicable)     Money Down:
Pop-up:  Truck Camper:  Travel Trailer:  5th Wheel:  Class B:  Class C:  Class A:   Length
Trade Information
Year:   Make:   Model:   Length:   Mileage:
Condition 1 to 10 (10 being showroom condition)       Balance Owed (if applicable)

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