Local Consumer Loan Application

Please fill out this secure form
Important: Please read these directions before completing this Application, and check the appropriate box below.

If you are applying for individual credit in your own name, and are relying on your own income or assets and not the income or assets of another person as the basis for repayment of the credit requested, complete only Sections A and D. If the requested credit is to be secured, also complete the first part of Section C and Section E.
 
If you are applying for joint credit with another person, complete all Sections except E, providing information in B about the joint applicant. If the requested credit is to be secured, then complete Section E.

WE INTEND TO APPLY FOR JOINT CREDIT:
Applicant Co-Applicant
 
If you are applying for individual credit, but are relying on income from alimony, child support, or separate maintenance or on the income or assets of another person as the basis for repayment of the credit requested, complete all Sections except E to the extent possible, providing information in B about the person on whose alimony, support, or maintenance payments or income or assets you are relying. If the requested credit is to be secured, then complete Section E.

Important Information About Procedures for Opening a New Account
To help the government fight the funding of terrorism and money laundering activities, the USA Patriot Act requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. What this means for you: When you open an account, we will ask for your name, physical address, date of birth, taxpayer identification number and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents. We will let you know if additional information is required.
 
 
SECTION A - INFORMATION REGARDING APPLICANT
Full Name (Last, First, Middle): 
 ext.
Are you a U.S. person? 

  

Drivers License Number: 
Social Security Number or Tax ID Number: 
Physical Residential:
(Street, City, State and Zip) 
Mailing Address:
 (Street, PO Box, City, State and Zip) 
How Long at Present Address: 
Email Address: 
Present Employer: 
Present Employer Address: 
Position or Title: 
How Long with Present Employer: 
Present Gross Salary or Commision:  per
Number of Dependents: 
Ages of Dependents: 
Alimony, child support, or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.
Alimony, child support, or separate maintenance received under: 


Other Income:  $ per
Sources of Other Income: 
Checking Account Balance: 
Checking Account - Where? 
Savings Account Balance: 
Savings Account - Where? 
Nearest Relative Not Living With You   
Name: 
Address: 
Relationship: 
Phone Number (including area code): 
 
SECTION B - INFORMATION REGARDING JOINT APPLICANT OR OTHER PARTY
Full Name (Last, First, Middle): 
 ext.
Are you a U.S. person?    
Drivers License Number: 
Social Security Number or Tax ID Number: 
Physical Residential:
(Street, City, State and Zip) 
Mailing Address:
 (Street, PO Box, City, State and Zip) 
How Long at Present Address: 
Email Address: 
Present Employer: 
Present Employer Address: 
Position or Title: 
How Long with Present Employer: 
Present Gross Salary or Commision:  per
Number of Dependents: 
Ages of Dependents: 
Alimony, child support, or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.
Alimony, child support, or separate maintenance received under: 


Other Income:  $ per
Sources of Other Income: 
Checking Account Balance: 
Checking Account - Where? 
Savings Account Balance: 
Savings Account - Where? 
Nearest Relative Not Living With You   
Name: 
Address: 
Relationship: 
Phone Number (including area code): 
 
SECTION C - MARITAL STATUS
(Do not complete if this is an application for individual unsecured credit.)
Applicant: 

(including single, divorced or widowed)
Other Party: 

(including single, divorced or widowed)
   
SECTION D - ASSET & DEBT INFORMATION
 
Automobile 1   
Make, Model, Year: 
Value:  $
Subject to Debt?    
Names of Owners: 
   
Automobile 2   
Make, Model, Year: 
Value:  $
Subject to Debt?    
Names of Owners: 
   
Landlord or Mortgage Holder: 
Type of Debt: 

  

Name in which Account is Carried: 
Original Debt (omit rent):  $
Present Balance (omit rent):  $
Monthly Payments:  $
Past Due?    
   
Other Obligations: 
(For example, liability to pay alimony, child support, separate maintenance 
   
SECTION E - SECURED CREDIT (Complete only if credit is to be secured.)
Briefly describe the property to be given as security:
Property Description: 
Names & Addresses of All Co-Owners of the Property: 
If the Security is Real Estate, Give the Full Name of Your Spouse (if any): 
   
DISCLOSURES
FEDERAL CREDIT APPLICATION DISCLOSURE: I applied for an extension of credit with you. You are soliciting, offering, or selling me an insurance product or annuity in connection with this extension of credit. FEDERAL LAW PROHIBITS YOU FROM CONDITIONING THE EXTENSION OF CREDIT ON EITHER: 1) My purchase of an insurance product or annuity from you or from any of your affiliates; or 2) My agreement not to obtain, or prohibition on me from obtaining, an insurance product or annuity from an unaffiliated entity.
   
SIGNATURES

Everything that I have stated in this Application is correct to the best of my knowledge. I understand that you will retain this Application whether or not it is approved. You are authorized to check my credit and employment history and answer questions about your credit experience with me.

Unless I have purchased the insurance product(s) by mail or if the Credit Disclosures are provided electronically, by signing below, I acknowledge that I have received the Credit Disclosures orally at the time I have applied for credit and fully understand the disclosures noted above. I am also being provided with a copy of these disclosures and I acknowledge receipt by my signature.

Applicant Signature:   
Date: 
   
Other Signature:   
Date: