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NAME: ______________________________________________ DOB: ______________ SOCIAL SECURITY #: _________________
Print                    First              Initial              Last

SPOUSE'S NAME: _____________________________________ DOB: _______________ SOCIAL SECURITY #: _________________
Print                             First           Initial            Last

HOME ADDRESS: ________________________________________________ Town: ___________________ ZIP: _______________

HOME PHONE: _________________________ DR. LIC.#: _______________________________ State Issued: __________________

SPOUSE'S DR. LIC. #: _______________________________ State Issued: __________________

Have you rented or leased retail space in the past? ______________. If Yes, ____________________________________________

Landlord's Name & Address: __________________________________________________ Phone: __________________________

Present Employer: __________________________________________________________________ How Long? _______________

Telephone: ___________________________________ Position: ______________________________________________________

Spouse's Employer: ___________________________________________________ Telephone: _____________________________

BANK & ADDRESS: ____________________________________________________ ACCT. NO.: __________________________

SCHEDULE OF ALL AMOUNTS OWED
        (Other than mortgages - list on back if necessary)

Description	Account No.	Monthly Payment	Balance Owing
TOTAL

Date:______________________________________

SIGNATURE: _________________________________________

SIGNATURE: _________________________________________

THE FHK COMPANIES
3300 Douglas Blvd., Suite 385
Roseville, CA 95661
Phone (916) 780-6670
Fax (916) 780-6746