Please bring this by our local office
or mail to us at:

ACCEPTANCE LOAN
COMPANY, INC
ATTN: CODY MESSER
1158 WEST FRONT STREET
THOMASVILLE, ALABAMA 36784
PHONE (334) 636-4933
FAX: (334) 636-1684

"For Fast and Courteous Service - Look to
ALC First"


Two Relatives, Addresses, and Telephone Number

Name_________________________________
Address ______________________________
City _________________________________
Phone _______________________________

Name_________________________________
Address ______________________________
City _________________________________
Phone _______________________________

Name_________________________________
Address ______________________________
City _________________________________
Phone________________________________

Name_________________________________ Name________________________________
SS#_________________________________ SS#___________________________________
Address______________________________ City__________________ State___________
Zip Code________________ Years Residence__________ No. Dependents____________
Home Phone# _______________________________________________________________
Employer __________________________ Employer_______________________________
Position ___________________________ Position ________________________________
Yrs Emp _______ Gross Income______ Yrs Emp ________Gross Income ____________
Employer Phone# ____________________Employer Phone# _______________________

Alimony, Child Supports, or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.

Other Income_______________________ Other Income____________________________
Do you have a ______________ Checking Account ____________ Savings Account?
If so, where? ___________________________________________________________
Do you own a ____Home ______Mobile Home _____Rent _____Other?
Monthly Payment ______________ Balance ____________Value _______________
Have you filed bankruptcy? ___________ Yes ___________ No
Auto _________________Yr ___________Mo Payment ___________Balance___________
Auto _________________Yr ___________Mo Payment ___________Balance___________
Other Creditors:_____________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
Dealer: Plaza Golf Cart Sales    Phone: 334-289-5891    Fax: 334-2895891     
Item Purchased:_____________________________________________________________
Sales Price _____________Down Payment ______________Amt. / Fin._______________

I certify that all of the above information is correct. I realize that by signing below I authorize you to check my credit and employment history and to ask any other question about my credit record.

___________________________________   _____________________________________
Applicant's Signature         Date         Co-Applicant's Signature       Date