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Living Room
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(630) 978-7000
1001 East Galena Blvd
Aurora, IL 60505
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1
Choose the Type of Account Application
Type of Application (Check One):
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2
Individual Applicant Information
First Name:
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Middle Initial:
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Last Name:
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Date of Birth:
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Billing Address is the same as the Mailing Address:
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Arizona
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California
Colorado
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Delaware
District Of Columbia
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Georgia
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Kansas
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Nebraska
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2a
Co-Applicant Information
First Name:
*
Middle Initial:
*
Last Name:
*
Date of Birth:
*
Social Security:
*
Language:
English
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Driver's License #:
*
Driver's License State:
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--Select--
Alabama
Alaska
Arizona
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California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
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Indiana
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Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
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Driver's License Expiration Date:
January
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May
June
July
August
September
October
November
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CoApplicantDriversLicenseExpYear
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
Home Phone:
*
Cell Phone:
Carrier:
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Sprint
T-Mobile
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Cricket
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Email Address:
*
Owns Home:
*
Rents
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Monthly Payment:
Mortgage / LandLord:
Street Address:
*
Apt. or Suite:
Mortgage / LandLord Phone:
City:
*
State:
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--Select--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Postal Code:
*
3
Individual Applicant Employer Information
Monthly Income:
*
Income Type:
*
Please Select
Job
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Disability
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How are you Paid:
Please Select
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Last Pay Date:
*
Next Pay Date:
*
Employer Name:
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Hire Date:
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Employer City:
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Employer State:
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Alaska
Arizona
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California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Employer Postal Code:
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3a
Co Applicant Employer Information
Monthly Income:
Income Type:
*
Please Select
Job
Social Security
Retirement/Pension
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How are you Paid:
Please Select
Weekly
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Last Pay Date:
*
Next Pay Date:
*
Employer Name:
*
Job Title:
*
Hire Date:
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Employer Phone:
Employer Street Address:
*
Employer Apt/Suite:
Employer City:
*
Employer State:
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--Select--
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Employer Postal Code:
*
4
Individual Applicant Bank Information
Bank Name:
*
Account Open Date:
*
Account Type:
*
Checking
Savings
Account Number:
*
Routing Number:
*
5
Individual Applicant References
Reference 1 Name:
*
Phone:
Reference1
*
Relationship:
Reference1
*
Reference 2 Name:
*
Phone:
Reference2
*
Relationship:
Reference2
*
Reference 3 Name:
*
Phone:
Reference3
*
Relationship:
Reference3
*
Has Applicant (Co-Applicant) ever declared Bankruptcy?
:
*
Has Applicant (Co-Applicant) ever declared Bankruptcy?
Yes
No
6
Previous Store Credit
Has Applicant (Co-Applicant) ever been extended credit through any Galena Furniture Warehouse Store?
':
*
Has Applicant (Co-Applicant) ever been extended credit through any Cheap Furniture Direct Test Store?
Yes
No
If Yes, Which Store?
Store:
*
Please Select
Galena Furniture
7
Disclaimer and Signature
Name of Spouse
:
Address of Spouse
:
Signature of Applicant
:
*
(By typing your name in this box, you are Legally signing this Document)
Signature of CO-Applicant
:
*
(By typing your name in this box, you are Legally signing this Document)
8
Select the Closest Store to Your Location
Send to Store:
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Please Select
Galena Furniture
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Please Print this Form out for your Own records*:
By clicking on the submit button, you have read, understood and accepted the terms in section 9 above:
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