commonwealth of puerto rico department of consumer affairs po box

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