Vmax Fitness Financing Application Complete and submit this form if you wish to use the monthly payment method. Applicant Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Phone*Email* Date of Birth* SSN*Driver License Number*Closest Relative (Not living with you)* First Last Phone Personal References (Not living with you)* First Last Phone Personal References (Not living with you)* First Last Phone Current Employer Name Phone How Long Work Address* Note / Special Instructions I HEREBY CERTIFY THAT THESE STATEMENTS ARE CORRECT TO THE BEST OF MY KNOWLEDGE AND ARE MADE FOR THE PURPOSE OF OBTAINING FINANCING FROM ACTIVE GIFTWARE INC, dba VMAX FITNESS. The applicant hereby authorizes Vmax Fitness and any of its representatives or partners to collect, use and disclose my personal information for the purposes of investigating and providing financial services. The applicant's personal information is collected, used and disclosed for the following purposes: (1) to collect credit report and related financial information from me, from credit agencies, and from any parties listed herein, (2) to use the information collected to determine my financial situation, (3) to share the information with assignees, bankers or funding partners of Vmax Fitness. Further, I specifically acknowledge that Vmax Fitness may assign this agreement and any related agreements in whole or in part from time to time and I agree that any personal information collected in relation to this agreement may be made available to any such proposed assignee, (4) to take collective action if account is outstanding for more than 30 days. YOU HAVE MY CONSENT TO OBTAIN MY CREDIT REPORT IN CONNECTION WITH MY APPLICATION FOR CREDIT AND FOR ANY OF THE FOLLOWING PURPOSES: EXTENDING CREDIT TO ME, INCREASING THE CREDIT LINE ON MY ACCOUNT, TAKING COLLECTION ACTION ON THE ACCOUNT, AND OTHER LEGITIMATE PURPOSES ASSOCIATED WITH THE ACCOUNT.
