THE NEW WAY TO APPROVE A MAN
(In the way of a Credit Application)
Name
Last First Middle
Address:
Address City State Zip
Telephone: Home # Work# Cell#
Date of Birth: Age SS#
Weight Height
Ethnicity: (check) Black Hispanic White Other
Do you live with any of the following: (circle)
Grandmother, Parents, Mother, Father, Girlfriend, Baby Mama, Alone, Shelter, Wife, Auntie, Other
Any Children (circle yes or no) Yes No
If yes, how many
How many Baby Mamas? If more than one, please name below.
Use separate sheet of paper if need more room.
1.
2.
3.
Ever been married (circle ) Yes No If yes, how many times?
Are you or have you ever been on the Down Low? (circle one) Yes No (If you answer "Yes" STOP RIGHT HERE!!)
Do you owe child support? Yes No Don't Know
*If your ex-wife, ex-girlfriend is getting state benefits (childcare, food stamps, etc), then you owe somebody something. Especially tax payers. Stop here and go take care of your dang kids.
Education:
Did you graduate from high school? (circle ) Yes No Name of high school (if yes)
Have you received any of the following? (Circle One) GED Diploma Nothing
*If you did not complete any of the above, please Stop here and return to school.
Any college? (circle one) Yes No Still Enrolled:Yes No Graduated
Have you ever been to jail? (circle one) Yes No If yes, what for? (be very specific)
Have you ever been to prison? (circle one) Yes No
*If you have answered yes to the above question, please Stop here and call your P.O. immediately.
Employed? (circle) Yes No *If no, please Stop here?
If yes, where and how long?
Do you have health insurance? Yes No
When did you last visit the dentist?
When was the last time you have been to the doctor? _ Yes No What for?
List any (all) illnesses. Use separate sheet of paper if needed.
Do you have or have you had any of the following? (please circle all that may apply)
Hepatitis A or B or C, Herpes, Mononucleosis, HIV/AIDS, The Bird Flu, West Nile Virus, Crabs, Chlamydia, Gonorrhea, SARS , Head Lice, Ringworms, Boils, Sex Change, Shingles, Meningitis , Measles, Mumps, Ebola Bunions Virus, A Cold, Something that you can't spell
*If you have circled any of these, Stop here do NOT turn in your application. See the doctor immediately!
Do you or have you ever used (ingested in any way) any of the following: (circle all that apply)
Crack/Cocaine Heroin Paint Markers Ecstasy Glue Bad pills Snuff
Anything under the kitchen sink
*Please use a separate sheet of paper to compile a list of goals and accomplishments.
By signing below, you agree that all of the information given above is true to the best of your knowledge. For my protection, you may be asked to provide the following information upon request: state ID, birth certificate, recent payroll stub, a recent clean bill of health from a certified physician or practitioner. Falsifying information may result in termination of this relationship (if applicable), and a severe a** whooping by my project cousins Pookie, Ray-Ray, Darnell, Lil Krazy or all of the above.
Applicants Signature Date:
Print Name :
