Use Spaces Below for Additional Items 
ARTICLE NUMBER 
IN CATALOG 
Quan¬ 
tity 
NAME AND VARIETY 
SIZE 
Price Each 
Loz , Lot 
etc. 
TOTAL AMOUNT 
Dollars 
Cents 
- 
Figure total of above items and include in space provided on other side 
Fill in and Sign This Form 
Cash Price of Amount Added 
This Order $_for Budget Plan $ 
Montgomery Ward & Co.: Send me the goods listed on the 
other side of this blank at the Budget Plan price indicated 
and apply the $_enclosed as a first payment. I will 
pay you at the place to which I send this order $_ 
within thirty days after I receive the goods and a similar 
amount monthly thereafter until the total Budget Plan price 
is paid. Until the goods are fully paid for, title and right of 
possession shall remain in you. 
if Ordering on Budget Plan 
Total Budget 
-Plan Price $_ 
I will not sell, remove, or encumber them without yeur writ¬ 
ten consent and 1 will assume any loss or damage to them. 
Should I fail to make any payment when due, you may re¬ 
take custody of goods at any time after such default or you 
may hold the undersigned jointly and severally for the full 
unpaid balance, which shall then become due and payable. 
I submit the following statement of facts to induce you to 
extend credit on this basis: 
I have lived here since_ 
( marriedN My 
or single/_age is_ 
If you are not 
in business for yourself, 
give name of employer_ 
Have you had a previous 
Budget Plan account with us?. 
( own my home \ 
rent or board /_My former address was_ 
( Minor must have order \ My occu- My average monthly 
signed by parent or guardian/ pation is_income for the past year $. 
(If housewife, give husband's occupation) 
Employer's Time worked 
____Address_____for him__ 
(If housewife, give name of husband's employer) 
Kind of merchandise bought 
_Where ?__and approximate date_ _ _ . 
Name and address of bank 
you do business with_ 
Please give here the names of 
Name 
Address 
.Business 
two references with whom you 
have had credit dealings . . . 
Business houses preferred. 
Name 
. Address 
.Business 
Your 
Shipping 
Point 
/If different\ 
1 from your I 
(Post Office / 
Your 
Signature 
State 
.Countv 
.Route 
Box 
Street and 
Number 
Wife’s or Husband’s Signature 
See instructions below* . 
Post 
Office 
State 
When the goods you are ordering are to be attached to land or buildings-such as heating and plumbing equipment, build¬ 
ing material, garages, roofing, fencing, paint, wall paper, electric light fixtures, pumping outfits, etc., also fill in following: 
Give complete address or location of property 
in which goods will be used or installed. Copy 
legal description from your deed or any tax bill. 
Name and address 
of Mortgage Holder_ 
How much have you 
paid on this property?. 
In whose name is the What is the total debt on Wkat is the value of the 
title to this property? -—_ ___property including mortgages? $_land and buildings? $_ 
•If customer is married and order totals more than $100, both husband and wife must sign;otherwise one signature only is required. 
