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1
Choose the Type of Account Application

Type of Application (Check One):



* Field is required.
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(Individual Account, complete sections 2 & 4 / Joint Account complete entire application)

2
Individual Applicant Information

First Name:*   Middle Initial:*   Last Name:*
Date of Birth:*   Social Security:*   Language:
Driver's License #:*   Driver's License State:*      
Home Phone:*   Cell Phone:   Carrier:
Email Address:*            
Owns Home:*
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  Monthly Payment:   Mortgage/LandLord:
Street Address:*   Apt. or Suite:   Mortgage/LandLord Phone:
City:*   State:*   Postal Code:*

2a
Co-Applicant Information

First Name:*   Middle Initial:*   Last Name:*
Date of Birth:*   Social Security:*   Language:
Driver's License #:*   Driver's License State:*      
Home Phone:*   Cell Phone:   Carrier:
Email Address:*            
Owns Home:*
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  Monthly Payment:   Mortgage/LandLord:
Street Address:*   Apt. or Suite:   Mortgage/LandLord Phone:
City:*   State:*   Postal Code:*

3
Individual Applicant Employer Information

Monthly Income:*   Income Type:*   Employment Kind:
How are you Paid:*   Last Pay Date:*   Next Pay Date:*
Employer Name:*   Job Title:*   Hire Date:*
Employer Phone:   Employer Street Address:*   Employer Apt/Suite:
Employer City:*   Employer State:*   Employer Postal Code:*

3a
Co-Applicant Employer Information

Monthly Income:*   Income Type:*   Employment Kind:
How are you Paid:*   Last Pay Date:*   Next Pay Date:*
Employer Name:*   Job Title:*   Hire Date:*
Employer Phone:   Employer Street Address:*   Employer Apt/Suite:
Employer City:*   Employer State:*   Employer Postal Code:*

4
Individual Applicant Bank Information

Bank Name:*   Account Open Date:*   Account Type:*
Account Number:*   Routing Number:*      

5
Individual Applicant References

Reference 1 Name:*   Phone:*   Relationship:*
Reference 2 Name:*   Phone:*   Relationship:*
Reference 3 Name:*   Phone:*   Relationship:*
Has Applicant (Co-Applicant) ever declared Bankruptcy? *
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6
Previous Store Credit

Has Applicant (Co-Applicant) ever been extended credit through any Cart04 Store? *
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  If Yes, Which Store?
            Srore:

7
Disclaimer and Signature

*Note: You do not need to disclose alimony, child support or separate maintenance income if you do not want us to consider it as a source for payment of this obligation. State Laws Require Us To Give The Following Notices: California Residents: Applicant if married may apply for a separate account. Ohio Residents: OHIO LAWS AGAINST DISCRIMINATION REQUIRE THAT ALL CREDITORS MAKE CREDIT EQUALLY AVAILABLE TO ALL CREDITWORTHY CUSTOMERS, AND THAT CREDIT REPORTING AGENCIES MAINTAIN SEPARATE CREDIT HISTORIES ON EACH INDIVIDUAL UPON REQUEST. THE OHIO CIVIL RIGHTS COMMISSION ADMINISTERS COMPLIANCE WITH THIS LAW. Wisconsin Residents: Marital Agreement Notice-No provision of a marital property agreement, unilateral statement under Sec. 766.59 Wis. Stats., or court decree under Sec. 766.70 Wis. Stats., will adversely affect our rights unless we are furnished a copy of the agreement, statement of decree, or we have actual knowledge of its terms, before credit is granted or the account is opened. We are required to ask married residents of Wisconsin for the following information:
Name of Spouse : Address of Spouse:
1. Your signature means that you apply to Seller for credit at the specific annual percentage rate in paragraph 2F of the Open End Credit Agreement and Truth in Lending Disclosures ("Agreement") that applies to the state in which you reside. 2. Your signature means that you have read and agree to the terms of the Agreement and that all purchases on your Account are subject to the Agreement. The information you furnish in this Application and on an alternate form, whether paper or electronic ("Application") is, to the best of your knowledge, complete and accurate and becomes part of the Agreement. You (a) agree that we may obtain credit reports on you in connection with your Application and may obtain subsequent credit reports to update, renew or extend additional credit for which you apply, verify information provided on your Application, and for all other lawful uses; (b) agree that your information in alternate application forms may be used. 3. You grant a purchase money security interest in the goods you purchase under the Agreement (see Paragraph 10) which are described in the invoices or similar forms issued by Seller and that they become part of the Agreement. 4. Your Application with your personal information may be forwarded for indirect financing to alternative finance sources, such as Tidewater Credit Services, LLC, who will have all Seller's rights under this Application and the Agreement. 5. You agree that even if financing promotions are associated with this Account, your first monthly payment must be received 30 days from the date you take delivery of any of the goods purchased under the Agreement. 6. You agree that we may place calls and send text and email messages to any telephone number or email address associated with your Account, and that your wireless service provider may charge you for such communications. You consent to our use of prerecorded or artificial voice messages and automatic dialing devices for such communications. You further agree that for Application and collection purposes, we may contact your employer, landlord, or third parties to verify your employment, residence, or location unless prohibited by law. 7. ACCOUNTS APPLIED FOR AT STORE KIOSKS ONLY: You are electronically signing an Application for credit via a store kiosk, and certify that you received, read, understand and agree to the terms of the Agreement.
Important Information About Opening a New Account: To help the government fight the funding of terrorism and money laundering activities, federal law requires all financial institutions obtain, verify and record information that identifies each person who opens an account. This means that when you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents.
The Open End Credit Agreement has an Arbitration Clause with a Class Action Prohibition (Parag. 7). You acknowledge that before signing below, you received a complete copy of the Agreement in a form you can keep, that you read it and understood its terms. NOTICES TO BUYER: You are requesting open end credit to finance the purchase of goods and related services from Seller. Do not sign this Application: (a) before you read it and the Open End Credit Agreement And Truth In Lending Disclosures, (b) if you did not initiate the request for credit, or (c) if you are unwilling to arbitrate disputes. You are entitled to an exact copy of the paper you sign to protect your legal rights. You have the right to pay in advance the full amount due at any time.
Signature of Applicant * : Signature of CO-Applicant * :

(By typing your name in this box, you are Legally signing this Document)


(By typing your name in this box, you are Legally signing this Document)

ASSIGNMENT BY SELLER. Seller assigns its interest in this Agreement to TIDEWATER CREDIT SERVICES, LLC, 6520 Indian River Rd., Virginia Beach, VA, 23464 ("Assignee") under the terms of a separate contract. This assignment is without recourse to Seller, except as set forth in a contract between Seller and Assignee.

8
Select the Closest Store to Your Location

Send to Store* :
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 7 above:


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