Fill out this form as completely as possible. Items marked with an asterisk (*) are required information. Send the form by checking the authorize box and clicking the submit button at the bottom of the page. Please allow 1 to 2 business days to process your request.
Name*
Email*
Date of Birth*
SSN*
Phone*
Current Address*
City*
State*
ZIP Code*
Own or Rent?* Own Rent
Monthly Payment or Rent*
How long?*
Previous Address
City
State
ZIP Code
Owned or Rented? Owned Rented
Monthly Payment or Rent
How long?
Name of a relative not residing with you*
Address*
Relationship*
Current Employer*
Length of Employment*
Email
Fax
Position*
Pay Type* Hourly Salary
Annual Income*
Previous Employer
Length of Employment
Address
Phone
Position
Pay Type Hourly Salary
Annual Income
Name
Date of Birth
SSN
Current Address
Own or Rent? Own Rent
Name of a relative not residing with you
Relationship
Current Employer
Lender
Account No.
Item numbers of the jewelry you would like to purchase*
Item Cost*
Comments or additional information you would like us to consider.
By checking this box, I authorize The Alexis Collection, LLC to verify the accuracy of the information provided on this form. *