CREDIT APPLICATION
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 eachperson who opens an account. What this means to 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.

AMOUNT REQUESTED $

PAYMENT DATE DESIRED

PROCEEDS OF CREDIT TO BE USED FOR

SECTION A - INFORMATION REGARDING APPLICANT
FULL NAME (Last, First Middle)	BIRTH DATE	HOME PHONE	BUSINESS PHONE and Extension

IF U.S PERSON: (Complete all that apply)	DRIVER'S LICENSE	STATE	DATE OF ISSUANCE	DATE OF EXPIRATION	SOCIAL SECURITY NO. or TAX I.D. NO.
	STATE ID CARD NO.	STATE	DATE OF ISSUANCE	DATE OF EXPIRATION	OTHER (MILITARY ID, TRIBAL ID, ETC.)

IF NON U.S PERSON: (Complete all that apply)	DRIVER'S LICENSE	STATE	DATE OF ISSUANCE	DATE OF EXPIRATION	social security no. OR TAX ID NO.	STATE ID CARD NO.	STATE	DATE OF ISSUANCE	DATE OF EXPIRATION
	PASSPORT NO. & COUNTRY OF ISSUANCE:		INDIVIDUAL TAXPAYER ID NO.		NO TAXPAYER ID NO., BUT HAVE FILED APPLICATION FOR ONE. WHEN FILED:		GOVERNMENT ISSUED DOCUMENT NO. AND COUNTRY OF ISSUANCE:		OTHER

PHYSICAL RESIDENTIAL OR BUSINESS STREET ADDRESS AND MAILING ADDRESS (Street, PO Box, City, State & Zip) or: IF MILITARY, APO OR FPO ADDRESS or; IF N/A, NEXT OF KIN OR FIREND								HOW LONG AT PRESENT ADDRESS
PREVIOUS ADDRESS (Street, City, State, & Zip)							HOW LONG AT PRESENT ADDRESS	EMAIL ADDRESS
PRESENT EMPLOYER (Company Name & Address)					OCCUPATION	POSITION OR TITLE	HOW LONG WITH PRESENT EMPPLOYER?	NAME OF SUPERVISOR
HOW LONG WITH PRESENT EMPLOYER	YOUR POSITION OR TITLE			NAME OF SUPERVISOR			BUSINESS PHONE                                   EXT.
PREVIOUS EMPLOYER (Company Name & Address)								HOW LONG WTIH PREVIOUS EMPLOYER

YOUR PRESENT GROSS SALARY OR COMMISSION $                                   per	YOUR PRESENT NET SALARY OR COMMISSION $                                   per	NO. 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, separate maintenance received under:   Court Order   Written Agreement  Oral Understanding.
OTHER INCOME $                                     per		SOURCES OF OTHER INCOME
Is any income listed in this Section likely to be     No reduced before the credit requested is paid off?    Yes (Explain)
Have you ever received   No credit from us?                Yes (Explain)		CHECKING ACCOUNT NO. ................................................wHERE?.......................................................... SAVINGS ACCOUNT NO.                                                     WHERE?
NAME AND ADDRESS OF NEAREST RELATIVE NOT LIVING WITH YOU                                                       RELATIONSHIP                                        TELEPHONE NO. (Include Area Code)

 

SECTION B- INFORMATION REGARDING JOINT APPLICANT OR OTHER PARTY (use separate sheets if necessary)
FULL NAME (Last, First Middle)	BIRTH DATE	HOME PHONE	BUSINESS PHONE and Extension

IF U.S PERSON: (Complete all that apply)	DRIVER'S LICENSE	STATE	DATE OF ISSUANCE	DATE OF EXPIRATION	SOCIAL SECURITY NO. or TAX I.D. NO.
	STATE ID CARD NO.	STATE	DATE OF ISSUANCE	DATE OF EXPIRATION	OTHER (MILITARY ID, TRIBAL ID, ETC.)

IF NON U.S PERSON: (Complete all that apply)	DRIVER'S LICENSE	STATE	DATE OF ISSUANCE	DATE OF EXPIRATION	social security no. OR TAX ID NO.	STATE ID CARD NO.	STATE	DATE OF ISSUANCE	DATE OF EXPIRATION
	PASSPORT NO. & COUNTRY OF ISSUANCE:		INDIVIDUAL TAXPAYER ID NO.		NO TAXPAYER ID NO., BUT HAVE FILED APPLICATION FOR ONE. WHEN FILED:		GOVERNMENT ISSUED DOCUMENT NO. AND COUNTRY OF ISSUANCE:		OTHER

PHYSICAL RESIDENTIAL OR BUSINESS STREET ADDRESS AND MAILING ADDRESS (Street, PO Box, City, State & Zip) or: IF MILITARY, APO OR FPO ADDRESS or; IF N/A, NEXT OF KIN OR FIREND								HOW LONG AT PRESENT ADDRESS
PRESENT EMPLOYER (Company Name & Address)					OCCUPATION	POSITION OR TITLE	HOW LONG WITH PRESENT EMPPLOYER?	NAME OF SUPERVISOR
HOW LONG WITH PRESENT EMPLOYER	YOUR POSITION OR TITLE			NAME OF SUPERVISOR			BUSINESS PHONE                                   EXT.
PREVIOUS EMPLOYER (Company Name & Address)								HOW LONG WTIH PREVIOUS EMPLOYER

YOUR PRESENT GROSS SALARY OR COMMISSION $                                   per	YOUR PRESENT NET SALARY OR COMMISSION $                                     per	NO. 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, separate maintenance received under:   Court Order   Written Agreement  Oral Understanding.
OTHER INCOME $                                     per		SOURCES OF OTHER INCOME
Is any income listed in this Section likely to be     No reduced before the credit requested is paid off?    Yes (Explain)
Have you ever received   No credit from us?                Yes (Explain)		CHECKING ACCOUNT NO. ................................................wHERE?.......................................................... SAVINGS ACCOUNT NO.                                                     WHERE?
NAME AND ADDRESS OF NEAREST RELATIVE NOT LIVING WITH YOU                                                       RELATIONSHIP                                        TELEPHONE NO. (Include Area Code)

SECTION C- MARITAL STATUS (Do not complete if this is an Application for individual unsecured credit.)

APPLICANT        Married Separated Unmarried (Including single, divorced,and widowed) OTHER PARTY  Married Separated Unmarried (Including, divorced, and widowed)

 

SECTION D - ASSET & DEBT INFORMATION
If Section B has been completed, this Section should be completed, giving information about both the Applicant and Joint Applicant or Other Person. Please mark Applicant-related information with and "A". If Section B was not completed, only give information about the Applicant in this Section.
ASSETS OWNED (Use separate sheet if necessary.)
DESCRIPTION OF ASSETS		VALUE	SUBJECT TO DEBT? Yes / No	NAMES OF OWNERS
CASH		$
AUTOMOBILES (Make, Model, Year) 1................................................................... 2................................................................... 3......................................................................		............................... ............................... ...............................	............................... ............................... ...............................	................................................................................... ................................................................................... ...................................................................................
CASH VALUE OF LIFE INSURANCE (Issuer, Face Value)
REAL ESTATE (Location, Date Acqired)
MARKETABLE SECURITIES (Issuer, Thype, No. of Share)
OHER (List)
TOTAL ASSETS		$

OUTSTANDING DEBTS (Include charge accounts, installment contracts, credit cards, rent, mortgages, etc. Use separate sheet if necessary)
CREDITOR	TYPE OF DEBT OR ACCOUNT NUMBER	NAME IN WHICH ACCOUNT IS CARRIED	ORIGINAL DEBT	PRESENT BALANCE	MONTHLY PAYMENTS	PAST DUE? Yes / No
LANDLORD OR MORTGAGE HOLDER	Rent Payment       Mortgage		(Omit Rent) $	(Omit Rent) $	$
TOTAL DEBTS			$	$	$

 

SECTION D - ASSET & DEBT INFORMATION (continued)
CREDITOR	TYPE OF DEBT OR ACCOUNT NUMBER	NAME IN WHICH ACCOUNT IS CARRIED	ORIGINAL DEBT	PRESENT BALANCE	MONTHLY PAYMENTS	PAST DUE? Yes / No
CREDIT REFERENCES (Paid Off Accounts)                                                                                                         DATE PAID OFF
MY AUTO INSURANCE AGENT IS: (Name & Address)
Are you a co-maker, endorser, or      No guarantor on any loan or contract?    Yes - For Whom?                                                                                                To Whom?
Are there any unsatisfied                   No judgements against you?                   Yes - Amount $                                                                           If "Yes", To Whom Owed?
Have you been declared bankrupt    No in the last 10 years?                          Yes - Where?                                                                                                               Year?
OTHER OBLIGATIONS (For example, liability to pay alimony, child support, separate maintenance. Use separate sheet if necessary.)

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):

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 authroized to check my credit and employment history and to answer questions about your credit experience with me.
APPLICANT'S SIGNATURE                                                            DATE x	OTHER SIGNATURE (Where Applicable)                                      DATE x