Credit Application
APPLICANT DATA   
Name(Last/First/MI): * ,
Email Address: * D.O.B.: *
Phone: * Fax:
SSN: * U.S. Citizen: Yes    No
Driver's License #   
A copy government issued ID is required to process this application -
Please attach / provide copy or we cannot proceed
Address: *
City: *
State: * Zip Code: *
Years there: Rent/Own: Rent    Own
Monthly Payment:
Personal Bank:  Phone
Landlord/Mortgage:
  Have you ever had a bankruptcy? If yes,  when
  Have you ever had repossesion, judgement or suit ? If yes,  when
Employment Information
Occupation: * Title:
Salary: *
Salary Period: * Hourly    Weekly    Monthly    Yearly   
Salary Other:
Employer Name: *
Employer Address:
Employer City:
Employer State:  Zip:
Employer Phone   Years there:
Personal Bank:  Phone
   
 
Signature:                                                                      Date                                     
 NOTICE FOR NEW YORK RESIDENTS – A consumer credit report may be requested in connection with this application or in connection with updates: renewals or extensions of any credit granted as a result of this application. If you subsequently ask for this information, you will be informed whether or not such a report was requested and, if so, the name and address of the agency that furnished the report.

NOTICE FOR OHIO RESIDENTS – The Ohio law against discrimination require that all creditors make credit equally available to all credit worthy customers, and that credit reporting agencies maintain separate credit histories on each individual upon request. The Ohio Civil Rights Commission administers compliance with this law.

NOTICE TO MARRIED WISCONSIN RESIDENTS – Wisconsin Law provides that no agreement, unilateral statement or court decree relating to marital property shall adversely affect a creditor’s interest, unless prior to the time of credit is granted the creditor is furnished a copy of the agreement, statement or decree or has actual knowledge of the adverse provision. You must indicate the name of your spouse on the Installment contract, and the address if different from yours.

NOTICE TO CALIFORNIA AND UTAH RESIDENTS – As required by law, you are hereby notified that a negative credit report reflecting on your credit record may be submitted to a credit reporting agency if you fail to fulfill the terms of your credit obligations.

NOTICE FOR MAINE RESIDENTS – If this application is approved by the creditor, you will be required to obtain and maintain physical damage insurance on the collateral securing the debt. You have a right of the free choice in the selection of the agent and the insurer through or by which the Insurance is placed.

IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING A NEW ACCOUNT: To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. What this means to you: When you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver’s license or other identifying documents.

AGREEMENT: By signing, applicant(s): 1. Certifies that the above information is true and complete as of the date shown below. 2. Agrees that this application is the property of the Bank and need not be returned to the applicant(s). 3. Authorizes the Bank to verify the accuracy and completeness of all information shown above from any source the Bank chooses. 4. Authorizes the Bank to answer questions from others about its credit experience with the applicant and to furnish such information to credit bureaus and share foregoing information consistent with its privacy policy. YOUR SIGNATURE DATE CO-APPLICANT’S SIGNATURE DATE*OTHER NET MONTHLY INCOME: You do not have to reveal alimony, child support or separate maintenance income unless you wish to have it considered for approving your application