Debts/Monthly Obligations
Please List All Monthly Obligations (e.g. Car Payments, Credit Cards, Medical Debts, etc.
Debt:		Monthly Payment:
Debt:		Monthly Payment:
Debt:		Monthly Payment:
Debt:		Monthly Payment:
Debt:		Monthly Payment:
Assets
Asset Type	Market Value	Loan Balance
Savings and Checking
Real Estate (Location)
Vehicle(Year, Make, Model)
Other(Describe)
Other(Describe)
Other(Describe)
Preferred Contact Method:Home PhoneCell PhoneWork Phone
Other Notes/Instructions

Signatures
Copy of Previous two Years Form W2, Previous Pay Stubs, or copy of 2 years Federal Income Tax Returns may be required to verify income Other Information not included on this form may be required for approval. By signing below I certify that all statements made on this application are true and complete. I authorize any person, association, firm, or corporation to furnish, on request of this Financial Institution, information concerning me and my affairs. (Sec. 1014, Title 18, U.S. Code makes it a Federal Crime to knowingly make a false statement on this application.)
If you have filled out this application as a joint applicant please print primary applicants name on the next line and sign below be sure to circle joint. If you are filling this out as the primary applicant circle primary and sign below.
Primary Applicant's Full Name(Please Print)
(Circle One)Primary / Joint Applicant Signature:		Date:

Personal Information
Primary ApplicantCo-Applicant	Marital Status:Married Single Divorced Seperated
Full Name (Last, First, Middle)
Date Of Birth:	No. of Dependants:	Ages of Dependants:
Home Phone:	Cell Phone:
Social Security No.:	Driver's License No. & State:
Residence Information
Street Address:
City:		State, Zip Code:
Time at Current Residence: Yrs. Mos.	Residence Type:Own RentOther:
Monthly Rent or Mortgage Payment:$	Landlord or Mortgage Holder:
Previous Address Information if under two years at Current Residence
Street Address:
City:		State, Zip Code:
Time at Previous Residence: Yrs. Mos.	Residence Type:Own RentOther:
Employment
Current Employer:		Work Phone Number:
Job Title:		Length of Employment: Yrs. Mos.
Gross Income:$ /per (Circle One) Hour Week Month		Supervisor:
Previous Employer if under two years at Present Employer
Previous Employer:		Work Phone Number:
Job Title:		Length of Employment: Yrs. Mos.
Gross Income:$ /per (Circle One) Hour Week Month		Supervisor:
Alimony, child support, or seperate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.
Source of Other Income:	Monthly Amount:
References Please List Nearest Relatives Not Living With You
Reference #1 Name(Last, First, Middle):
Street Address:
City:		State, Zip Code:
Phone:		Relationship:
Reference #2 Name(Last, First, Middle):
Street Address:
City:		State, Zip Code:
Phone:		Relationship: