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4 MUFN'I‘AIN INVES'I‘MENT, INC.
P. 0‘ BOX 35’! PLEASE ADDRESS REPLY To.
WHEELWRIGHT. KENTUCKY 41669 PHONE 606.457.276‘
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APPLICATION FOR CREDIT
To Mountain Investment, Inc:
Name 1 5141.0 Ki {4). 1 ZQ/L/flr/Jj’flv Age c)? j“ ’
Number of Dependents 1 Ages [U 1" Q - 2 3
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Present (or last) permanent address [UL/1 ,1 11 1,
Telephone No. 322. Q (is/Z
Local Address
Telephone No.
Present Employment:
Employer‘s name and address “’6 1 (932A, fl/lML/LLCQZV ?Mf’xuaé/
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Division or Department Badge No.
Present position
Length of service ég 21 11,3 ‘zi 2 67) /[;:Z()
7” 50 ”D ' 12
Previous Employment: / ' COX/bk fé/
Employer‘s name and address
Division or Department Badge No.
Position held
Length of service
. Bank Reference: Name {gripe/ii :3 ) Qikgm 2 5L Baum/é;
Address Lg; kg Q/kabgltcuw? & 9
Automobile: Maketmggg Q} \L 4)OJ% O/[algiModel
Year 2;? it A ? License No.
Trade references:
1. Name 24 ,Iu ‘ (7
Address / I, ., L, d
2. Name J gig/5; 5A 1225‘; 22214.,
AddreSS ééé $118 E5763”! E'IZL/ (é éé,fi a gqég 1"!) Eg a (2 gem L,
3. Name ‘JD 2921: a fly :15 3 J4Lk¢vng :11-
Address 9%,: _ éég : {L/
. Reason for interest in living
in Wheelwright 3 )QQQQ egg/tag, Q“ (:5 g g Q 9969: I
The foregoing statements are true and are made to induce you to
extend credit for rent, gas, water, sewer and garbage collection to me.
I agree that any payments made by me may be applied by you, in your dis—
cretion, on any account owing by me.
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Number of Dependents / Ages “(L/’{é'g a? 3
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’ Division or Department ‘ Badge No.
Present position
Length of service xii/9i, jfi I (N), )9 20
Previous Employment: 15’ [gm/43
Employer‘s name and address I
Division or Department Badge No.
Position held W
Length of service W
Bank Reference: Name .Q‘Lxg}: j )gfi :1 gm: ,3 g 8524,, é
Address 525 g 1, E2913 giro/3:45. (a, I _
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Automobile: Malt {gov/g; ,(_’XatmrLI\/lodel
Year’ 22 + 5 Y License No.
Trade references: T k
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‘ Address ' B.CLCZC:.