commonwealth of puerto rico department of consumer affairs po box
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COMMONWEALTH OF PUERTO RICO DEPARTMENT OF CONSUMER AFFAIRS PO BOX 41059 SAN JUAN PR 00940-1059 PERSONAL HISTORY Re: Name of Applicant 1. Name (last name) (first name) (initial) 2. Residential Address Telephone Mailing Address 3. Date & Place of Birth ( )( )( ) 4. Social Security Number 5. Civil Status: Single 6. Are you a U.S. Citizen? Occupation Married Yes Divorced No 7. Spouses Name 8. Father's Name 9. Mother's name 10. Current Position 11. References: A. Personal: Name Address Telephone 1 2 3 B. Credit: 1. Name Account # Address Telephone 2. Name Account # Address 3. Name Account # Address * If you are a naturalized American citizen, submit copy of naturalization certificate. 12. Employment Experience (last 5 years) A. Name and Address of Employer Immediate Supervisor Dates B. Name and Address of Employer Immediate Supervisor _ Dates C. Name and Address of Employer Immediate Supervisor Dates 13. A. Assets B. Liabilities: Creditor Type of Debt Account 14. Please include the following: 2" x 2" photo. Written authorization to creditors allowing us to check references. No debt certificate (local Department of Treasury) . Negative penal record certificate (local Police Department). 3 letters of personal references and 3 letters credit references. Copy of your Financial Statements for the last year. 1 Certify: That all the information given above is correct ad I further authorize The Department of Consumer Affairs, or a representative, to obtain where necessary, information pertinent for the evaluation of application. Date Signature the referred
