1675 North Second West, Post Office Box 400
Provo, Utah 84604 Telephone(801)3749500
Name and Address of Payor of Any Alimony, Child Support, or Maintenance Payment Disclosed Above and Relied Upon as
a Source of Repayment.
Where Does Co-Applicant Bank? Branch No. Yrs.
Type of Account: No.
Other Bank or Credit Union Branch No. Yrs.
Have You Ever Borrowed From Any Other Branch of This Bank? Yes No
Which Branch? When?
Applicant desires the following voluntary insurance: Credit life Credit disability Both
Co-applicant desires the following voluntary insurance: Credit life Credit disability Both
Agent for Hazard and Liability Insurance (name, address, telephone):
I (we) hereby affirm that the information contained in this application, including the information on the reverse side, is
true, complete and correct and that Lender is relying on this information if it makes the requested loan. Lender is
authorized to make any investigation of my / our credit and / or employment status either directly or through any agency
employed by Lender. Lender may disclose to any other interested parties Lender’s experience with my / our loan account.
Lender may keep this application even it it decides not to make the loan to me / us.
Co-Applicant’s or Other Party Signature
Mailing Address Mailing Address
SPOUSAL CONSENT (If you are relying on income from your spouse or former spouse who is not an applicant above,
please have your spouse or former spouse complete this section so that we may verify their credit.)
I authorize Lender to make any investigation of my credit either directly or through any agency employed by Lender for
that purpose in connection with this credit application by my spouse or former spouse.
Signature Social Security Number