Apply for a Michaud & Raymond Account

Name: Email:
Address: Apt/Suite#:
City: State: Zip:
Years There: Rent or Own:

If renting
Landlord Name: Landlord Address:
Landlord Phone#:  

Your Employer: Employer Phone#:
Employer Address: Employer City State Zip:
Years There:  

Employer: Phone#:

Notice: By submitting this form, I hereby authorize you or any credit reporting agency employed by you to investigate the references herein listed or any of the other information stated above to determine my qualifications for a credit account. I also understand that after credit established any balance remaining unpaid 30 days after billing date is subject to a finance charge at a periodic rate of 1.5% per month (18% annually). The undersigned guarantees payment of any debt or reasonable collection cost incurred.