Please complete this form and click the Submit button. 

Personal Information
First Name	*
Middle Name
Last Name	*
Age	*
Date of Birth	*
Contact Information
Home Phone #	*
Cell Phone #	*
Mailling Address: Street	*
Mailing Address: City and Zip	*
Mailing Address: State	*
Physical Address, if different
How Long at Address
Former Address if less than one year
Rent/Own	*	Rent Own Other
Monthly Payment	*
Landlord or Mortgage	*
Employment Information
Employer	*
Employer Address	*
Employer Phone #	*
Occupation (Work As)	*
How Long	*
Monthly Salary	*
Other Income Source	*
Other Income	*
Marital Status and Spouse Information
Marital Status	*	Single Married Divorced Widowed
# of people in family	*
Ever had an account with Pedigo Furniture?	*	Yes No
Under what name?	*
Enter N/A if NOT Applicable
Spouse's Full Name (if applicable)
Age
Date of Birth
Spouse's Phone Number
Spouse's Employer
Employer Address
Employer Phone #
Occupation (Work As)
How Long
Monthly Salary
Other Income Source
Other Income
Financial Information
Name of Bank	*
Account Type	*	Checking Savings
Auto Year & Make	*
Monthly Payment	*
Personal References: Two Relatives and One Friend NOT Living with You
Name of Relative / Address, City, State, Zip / Phone # /Relation	*
Name of Relative / Address, City, State, Zip / Phone # /Relation	*
Name of Friend / Address, City, State, Zip / Phone #	*
Driver's License	*
State ID Issued	* State that issued ID	- - Choose One - - AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
SS#	*
Spouse's Driver's License (if applicable)
State ID Issued	State that issued ID	- - Choose One - - AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Spouse's SS#
Email	*
Preferred Sales Associate	If applicable	Choose Below Sarina Kesler Somer Jacobs Debbie Pantalion Jennifer Sessions Allison Evans Melissa Dodge
Preferred method of contact for approval.	* We will contact you via your preferred method of notification.	Choose Below Via Phone Via Email In Store
I verify that the foregoing statements are correct to the best of my knowledge. I give Pedigo Furniture, Inc. permission to make all inquiries deemed necessary to verify the accuracy of the statements made herein, and to determine credit worthiness by procuring consumer reports and credit information from consumer reporting agencies, other financial institutions, and references. All information can be used for collection purposes.
Electronic Signature Entering Name is agreeing to the above statements and conditions. Enter Full Name
Security Code	* Enter code in image to submit form