Fill and Sign the Section a Credit Application Important Read These Directions Form

- 1 - CONSUMER LOAN APPLICATION IMPORTANT: Read these Directions before completing this Application. Check Appropriate Box:[ ] If you are applying for individual credit in your own name, are not married, and are not relying on alimony, child support, or separate maintenance payments or on 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 Section E.[ ] In all other situations, complete all Sections except E, providing information in B about your spouse, a joint applicant or user, or the person on whose alimony, support or maintenance payments or income or assets you are relying. If the requested credit is to be secured, also complete Section E.YOU MAY APPLY FOR A SEPARATE ACCOUNT, EVEN IF YOU ARE MARRIED.Amount Requested: $_____________________ Payment Date Desired:____________________________Proceeds of Credit to Be Used for: _________________________________________________________SECTION A - INFORMATION REGARDING APPLICANT___________________________________________ _______________ _______________________Full Name (Last, First, Middle): Date of Birth TelephoneAddress________________________________________ City/St/Zip_______________________________Years there: ____ Social Security No.:_______________________ Driver's License No.:________________Previous Address: __________________________________________________ Years there: ___________Present Employer: _____________________________________How Long?: _____ Phone:______________Address:__________________________ Your Position: ____________ Supervisor:____________________Previous Employer: _____________________________________Years there: _____ Phone:______________Address:__________________________ Your Position: ____________ Supervisor:____________________Present Net Salary or Commission:$_____________________________ per __________________________No. Dependents: ____________________________ Ages:_________________________________________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, separate maintenance received under:[ ] Court Order [ ] Oral Understanding [ ] Written Agreement - 2 - Other Income: $_____________ per________ Sources of Other Income:_____________________________Is any income listed in this section likely to be reduced in the next two years or before the credit requested is paid off? [ ]Yes (Explain in detail on separate sheet.) [ ] NoHave you ever received credit from us? ________ When? __________________________________________Your Bank_____________________________ Branch______________ Account No:_ ___________________Nearest relative not living with you: ________________________________ Relationship: _______________Address: _______________________________________________________ Telephone_________________SECTION B - INFORMATION REGARDING SPOUSE, JOINT APPLICANT, USER, OR OTHER PARTY (Use separate sheets if necessary.)___________________________________________ _______________ _______________________Full Name (Last, First, Middle): Date of Birth TelephoneAddress________________________________________ City/St/Zip_________________________________Years there: ____ Social Security No.:_______________________Driver's License No.: _________________Previous Address: ______________________________________ How Long?:_____Phone:_______________Present Employer: _____________________________________ How Long?:_____Phone:_______________Address:__________________________ Your Position: ____________ Supervisor:____________________Previous Employer: _____________________________________How Long?:_____ Phone:______________Address:__________________________ Your Position: ____________ Supervisor:____________________Present Net Salary or Commission:$_____________________________ per ___________________________No. Dependents: ____________________________ Ages:_________________________________________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, separate maintenance received under:[ ] Court Order [ ] Oral Understanding [ ] Written Agreement - 3 - Other Income: $_____________ per________ Sources of Other Income:________________________ Is any income listed in this section likely to be reduced in the next two years or before the credit requested is paid off?[ ]Yes (Explain in detail on separate sheet.) [ ] NoHave you ever received credit from us? ________ When? __________________________________________Your Bank_____________________________ Branch______________ Account No: ____________________Nearest relative not living with you: ________________________________ Relationship:________________Address: ___________________________________________________ Telephone_______________SECTION C - MARITAL STATUSApplicant: [ ] Married [ ] Separated [ ] Unmarried (includes single, divorced, and widowed.)Other Party: [ ] Married [ ] Separated [ ] Unmarried SECTION D - ASSET AND DEBT INFORMATION(If Section B has been completed, this Section should be completed by giving information about both the Applicant and Spouse, Joint Applicant, User, or Other Person. Please mark Applicant - related information with an "A." If Section B was not completed, only give information about the Applicant in this Section.)Assets: Description Cash or Market ValueCash in Bank:Checking Account $_____________Savings Account______________Credit Union______________Stocks and Bonds______________Cash Value of Life Insurance______________Automobile______________Furniture and Personal Property______________Real Estate Owned ______________Vested Interest in Retirement Fund ______________Net Worth of Business Owned ______________Other Assets _________________ ______________Total Assets $_____________Outstanding Debts Creditors Name, Address, Unpaid Monthly and Account Number Balance Payment_______________________________________________ $____________ $___________________________________________________________ $____________ $____________ - 4 - _______________________________________________ $____________ $___________________________________________________________ $____________ $___________________________________________________________ $____________ $___________________________________________________________ $____________ $___________________________________________________________ $____________ $____________Automobile Loan _______________________________ $____________ $____________Real Estate Loan ________________________________ $ ____________ $____________T O T A L_______________________________________ $_____________ $____________Previous Credit ReferencesCreditor's Name_______________________________Acct #______________ Date Paid____________Address______________________________________Purpose_____________ High Balance_________Creditor's Name_______________________________Acct #______________ Date Paid ____________Address______________________________________Purpose_____________ High Balance_________Creditor's Name_______________________________Acct #______________ Date Paid ____________Address______________________________________Purpose_____________ High Balance_________Are there any judgments against you? [ ] Yes [ ] No. To whom:______________ Amt.$__________Have you been declared bankruptcy in the last 14 years? [ ] Yes [ ] No. Where________ Year_____Other obligations (For example, liability to pay alimony, child support, separate maintenance. Use separate sheets if necessary.):________________________________________________________________________________________________________________________________________________________________________________SECTION E - SECURED CREDIT (Complete only if credit is to be secured.)Briefly describe the property to be given as security:_______________________________________________ ________________________________________________________________________________________List names and addresses of all co-owners of the property:Name Address________________________________________________________________________________________ - 5 - ________________________________________________________________________________________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 to answer questions about your credit experience with me.Dated: __________________________ _____________________________________________ ApplicantDated: __________________________ ____________________________________________ Joint Applicant