Simply print this form, fill it out, and fax it or bring it with you to AMDS.

Consumer Credit Application
Alaska Mining & Diving Supply  3222 Commercial Drive  Anchorage, Alaska  99501
Phone 907-277-1741    Fax 907-258-3161   email finance@akmining.com

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Name (First, Middle, Last)                                      Item to Finance/Finance Amount

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Mailing Address (Street or Box, City, State, Zip Code)                       How Long?

________________________________________________________     ____________
Physical Address (Street, City, State, Zip Code)                               How Long?

__________________    _________________
Home Phone                 Work Phone

_________________________
Date of Birth
______________________________
Social Security Number		______________________
Driver License Number/State
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Current Employer/Position or Grade		__________________
Length of Employment
_____________________
Monthly Gross Salary		_________________________
Additional Income/Source
________________________________________
Relative NOT Living With You - Name and Phone		_________________________
Bank Name and Location
Own     Rent     Other     (Circle One)
____________________
Rent/Payment per Month
The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin or sex, marital status, age (provided that the applicant has the capacity to enter into a binding contract); because all or part of the applicant’s income derives from any public assistance program: or because the applicant has in good faith exercised any right under the Consumer Protection Act. The Federal agency that administers compliance with this law concerning this creditor is the Federal Deposit Insurance Corporation Regional Director, 25 Eckert Street, Suite 2300, San Francisco, California 94105.
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Signature		____________________
Date
TO HELP the government fight the funding of terrorism, money laundering activities, and various forms of fraud, such as identity theft, Federal law requires financial institutions to obtain, verify, and record information that identifies each person that opens an account. We may ask to see your driver’s license or other identifying documents.