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Credit Application	
IMPORTANT: Please read these directions before completing this Application, and check the appropriate box below.
o	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.
o	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.
o	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 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.	
AMOUNT REQUESTED $	PAYMENT DATE DESIRED	Proceeds of Credit to be used for	
SECTION A - INFORMATION REGARDING APPLICANT	_	_	
FULL NAME (Last, First Middle)	BIRTH DATE	DRIVERS LICENSE NO.	SOCIAL SECURITY NO.	
PRESENT ADDRESS (Street, City, State, & Zip)	HOW LONG AT PRESENT ADDRESS?	HOME PHONE	
PREVIOUS ADDRESS (Street, City, State, & Zip)	HOW LONG AT PREVIOUS ADDRESS?	EMAIL ADDRESS	
PRESENT EMPLOYER (Company Name & Address)	
HOW LONG WITH PRESENT EMPLOYER?	YOUR POSITION OR TITLE	NAME OF SUPERVISOR	BUSINESS PHONE	Ext.	
PREVIOUS EMPLOYER (Company Name & Address)	HOW LONG WITH 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, or 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        O	No
Reduced before the credit requested is paid off?     O    Yes (Explain)	
Have you ever received      O	No
Credit from us?                  O	    Yes - When?	Checking Account No.	Where? 	
Savings Account No.	Where?	
NAME & 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	DRIVERS LICENSE NO.	SOCIAL SECURITY NO,	
RELATIONSHIP TO APPLICANT (If Any)	PRESENT ADDRESS (Street, City, State, & Zip)	HOW LONG AT PRESENT ADDRESS?	HOME PHONE	
PRESENT EMPLOYER (Company Name & Address)	
HOW LONG WITH PRESENT EMPLOYER?	POSITION OR TITLE	NAME OF SUPERVISOR	BUSINESS PHONE	Ext.	
PREVIOUS EMPLOYER (Company Name & Address)	
HOW LONG WITH 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, or 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          O	   No
Reduced before the credit requested is paid off?	     O    Yes (Explain)	
Has Joint Applicant or Other Party         O	 No
Ever received credit from us?	      O     Yes	Checking Account No.	 Where? 	
Savings Account No.  ……………………………………….    	Where?  ………………………………………………………………………………..	
NAME & ADDRESS OF NEAREST RELATIVE NOT LIVING WITH YOU	
SECTION C - MARITAL STATUS (Do not complete if this is an Application for individual unsecured credit.)	
APPLICANT	 Married  Separated  Unmarried (Including single, divorced, or widowed)
OTHER PARTY	 Married  Separated  Unmarried (Including single, divorced, or widowed)	
© Professional Bank Forms Co.; Box 759; Oxford, KS 67119	Form 501CD – 8/02

SECTION D - ASSET & DEBT INFORMATION	
If Section B has been completed, this Section should be completed, giving information	Applicant-related information with an "A". If Section B was not completed, only give
About both the Applicant and Joint Applicant or Other Person. Please mark	Information about the Applicant In this Section.	
ASSETS OWNED (Use separate sheet if necessary.)	
DESCRIPTION OF ASSETS	VALUE	SUBJE CT 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, Data Acquired)				
MARKETABLE SECURITIES (issue Type, No of Shares)				
OTHER (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	O    Rent                 O    Mortgage		(Omit Rent)
$	(OMIT Rent)
$	$		

							

							
TOTAL DEBTS			$	$	$		
CREDIT REFERENCES (Paid Off Accounts)	DATE PAID OFF	
			$	
				
MY AUTO INSURANCE AGENT IS: (Name & Address)		
Are  you the co-maker, endorser,                   O        No
Or guarantor and any loan Or contract?           O       Yes - For Whom?	To Whom?	

Are there any unsatisfied judgments                 O	    No
Against you?                                                         O     Yes - Amount $	II "Yes", To Whom Owed?	
Have you been declared bankrupt t in the            O	 No
Last 10 Years?                                                                  O        Yes - Where?	Year?	
OTHER OBLIGATIONS (For example, liability to pay alimony, child support, separate maintenance. Use separate sheet it 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 AND  ADDRESSES OF ALL CO-OWNERS OF THE PROPERTY	
IF THE SECURITY IS REAL ESTATE, GIVE THE FULL NAME OF YOUR SPOUSE (II any):

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Credit Disclosures:  An insurance product or annuity may be offered to you.  If you purchase an insurance product or an annuity:  (1) The insurance product or annuity is not a deposit or other obligation of, or guaranteed by, this institution or our affiliate(s); (2) with exception of Federal Flood Insurance or Federal Crop Insurance, the insurance product or annuity is not insured by the Federal Deposit Insurance Corporation or any other agency of the United States, this institution, or our affiliate(s); and (3) in the case of an insurance product or annuity that involves an investment risk, there is investment risk associated with the insurance product, including the possible loss of value.  If an insurance product or annuity is offered we cannot condition an extension of credit on either of the following:  (1) Your purchase of an insurance product or annuity from us or any of our affiliates; or 2) Your agreement not to obtain, or a prohibition on you 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.
APPLICANTS SIGNATURE                                             DATE                                     OTHER SIGNATURE (WHERE APPLICABLE)                            DATE