Credit Prequalification Application

TYPE OF CREDIT REQUESTED
IMPORTANT: Check the appropriate boxes below and complete the applicable sections.
	SECURED	INDIVIDUAL CREDIT - relying solely on my income or assets.
	UNSECURED	INDIVIDUAL CREDIT - relying on my income or assets as well as income or assets from other sources
		JOINT CREDIT

AMOUNT REQUESTED	FOR HOW LONG	PAYMENT DATE DESIRED	WANT TO REPAY		PROCEEDS OF LOAN TO BE USED FOR
$			Monthly Other

SECTION A - INDIVIDUAL APPLICANT INFORMATION
NAME (Last, First Middle)	PHONE	S.S. NUMBER	NO. DEPENDENTS	DEPENDENT AGES
ADDRESS (Street, City, State, ZIP)	DATE OF BIRTH	COUNTY	DO YOU Own Rent	HOW LONG
PHONE NUMBER		EMAIL ADDRESS
EMPLOYER (Company Name & Address)				HOW LONG
BUSINESS PHONE	EXT.	POSITION/TITLE	SALARY PER MONTH Gross: $ Net: $
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
SOURCES OF OTHER INCOME	AMOUNT PER MONTH $	HAVE YOU PREVIOUSLY RECEIVED CREDIT FROM US? WHEN:

SECTION B - JOINT APPLICANT OR OTHER PARTY INFORMATION
RELATIONSHIP TO APPLICANT (if any)
NAME (Last, First Middle)	PHONE	S.S. NUMBER	NO. DEPENDENTS	DEPENDENT AGES
ADDRESS (Street, City, State, ZIP)	DATE OF BIRTH	COUNTY	DO YOU Own Rent	HOW LONG
PHONE NUMBER		EMAIL ADDRESS
EMPLOYER (Company Name & Address)				HOW LONG
BUSINESS PHONE	EXT.	POSITION/TITLE	SALARY PER MONTH Gross: $ Net: $
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
SOURCES OF OTHER INCOME	AMOUNT PER MONTH $	HAVE YOU PREVIOUSLY RECEIVED CREDIT FROM US? WHEN:

SECTION C - MARITAL STATUS
APPLICANT	Married	Separated	Unmarried (including single, divorced, and widowed)
OTHER PARTY	Married	Separated	Unmarried (including single, divorced, and widowed)

Complete the following information about both the Applicant and Joint Applicant or Other Person (if applicable):

Are you obligated to make Alimony, Support or Maintenance Payments? No Yes

If yes, to (Name & Address): Amt. Per Month: $

Are you a co-maker, endorser, or guarantor on any loan or contract? No Yes

If yes: For whom? To whom?

Are there any unsatisfied judgments against you? No Yes If yes, to whom? Amount: $

Have you been declared bankrupt in the last 10 years? No Yes If yes, where? Year

SECTION E - SECURED CREDIT
Complete only if credit is to be secured. Briefly describe the property to be given as security:
PROPERTY DESCRIPTION
NAME & ADDRESS OF ALL CO-OWNERS OF THE PROPERTY

FEDERAL CREDIT APPLICATION INSURANCE DISCLOSURE: I have applied for an extension of credit with you. You are soliciting, offering, or selling me an insurance product or annuity in connection with this extension of credit. FEDERAL LAW PROHIBITS YOU FROM CONDITIONING THE EXTENSION OF CREDIT ON EITHER: 1) My purchase of an insurance product or annuity from your or from any of your affiliates; 2) My agreement not to obtain, or a prohibition on me from obtaining, an insurance product or annuity from an unaffiliated entity. By signing, I acknowledge that I have received a copy of this form on today's date. Unless this disclosure is provided electronically or I have applied for credit by mail, I also acknowledge that you have provided this disclosure to me orally.

I CERTIFY that everything I have stated in this application and on any attachments is correct. You may keep this application whether or not it is approved. By clicking the "Submit" button below, I authorize you to check my credit and employment history and to answer questions others may ask you about my credit record with you. I understand that I must update credit information at your request if my financial condition changes.