About Us     Apply for Credit     Product Display     Website Package     Home Add Member Details For Credit Card Please complete the following form to apply for your Credit Card today. All fields marked with * are required. Personal Information Mr. Ms. Mrs. Dr. Title : (Mr. Ms. Mrs. Dr.) * First Name Middle Name (If Applicable) * Last Name * Date of Birth (MM/DD/YYYY) - - Social Security Number Driving License Number Single Married Widow Marital Status Spouse Full Name (If Applicable): - - Social Security Number (For Spouse) Are You a U.S. Citizen : Yes No Residential Information Employment Information Current Address Company Name City State Zipcode Company Address Home Owner : Yes No City State Zipcode No. of Years in the Current Address Telephone Position Held No. of Years Telephone $ Annual House Hold Income $ Annual Income Address For Correspondence (Leave Blank if Same as Residence Address) Address * Email Address **We may use your email address to send the information about products and services you might find useful. It will not disclosed to anybody else. City State Zipcode Telephone References   Reference1  (Please Print First Name, Last Name, City-State-Zip of Work and Telephone Numbers with Extension if Available) Reference2   (Please Print First Name, Last Name, City-State-Zip of Work and Telephone Numbers with Extension if Available) Login Details Login Name : * Password : * Confirm Password : Please attach the copies of following necessary documents: (If documents are not ready please mail them later at info@jewelry-lease.com.) 1. Driving License 2. Proof of address 3. Major Credit Card    Everything that I have stated in this application is correct to the best of my knowledge. I understand that jewelry-lease will retain this application whether or not it is approved. jewelry-lease and others on behalf of jewelry-lease are authorized to verify any other information I may have submitted to them, and check my credit and employment history.   ©2004 Jewelry-Lease. All rights reserved.