,
*
-
VMPC148 (1211).00
UCA 11/1/2012
Page 1 of 4
VMP
Universal Credit Application
1986, 2012Wolters Kluwer Financial Services
Custom MDF. EARUCA1Bankers Systems
Credit Application
Important Information to Applicant(s).
What this means for you.
Security for CreditLoan Purpose
First Payment Date
Proceeds of Credit to Be Used for
Repayment Interval
$
Previous Address
Primary Phone
No. of Months
Credit Type
Amount Financing Type
Gov't ID Type Gov't ID No. Gov't ID Issued By
Gov't ID Issue Date Gov't ID Exp. Date Date of Birth
Soc. Sec. No.
Email Address:
Present Address
Second Phone
Application Date
Joint Credit -Individual Credit -
Nearest Relative
Your Relationship to us (or our affiliate)
Dependents
Full Name
Previous Address
Primary Phone
Have you ever received credit from us?
Gov't ID Type Gov't ID No. Gov't ID Issued By
Gov't ID Issue Date Gov't ID Exp. Date Date of Birth
Soc. Sec. No.
Email Address:
Present Address
Second Phone
Nearest Relative
Your Relationship to us (or our affiliate)
Dependents
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 applies for a loan or opens an account.
When you apply for a loan or 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. In some instances,
we may use outside sources to confirm the information. The information
you provide is protected by our privacy policy and federal law.
Account No. Class No. Date Received
Name:
Address:
Telephone:
( means Applicant, ; and means Creditor)
Monthly
Joint ApplicantApplicant
By initialing below, you intend to apply for "joint credit".You are relying solely on your income or assets.
To purchase property that will secure your credit
To purchase property that is a residential dwelling and is not real estate
To finance home improvements to a residential dwelling
Other
New
Refinance
Line of Credit
Loan
Sale
Lease
Agricultural
Business
Consumer
Unsecured
Secured
Insider (Shareholder, Director, Officer)
No. of Yrs.:
EmployeeNone
Own
Ages:
Rent
Own Rent No. of Yrs.:
No.:
CellCell
Name:
Address:
Telephone:
Insider (Shareholder, Director, Officer)
office/branch:
No. of Yrs.:
If yes, when:
EmployeeNone
Own
Yes
Cell
Ages:
Rent
Own Rent
No
No. of Yrs.:
No.:
CellCell Cell
Read each instruction carefully before completing this form.
Type of Requested Credit
Type of Application
Applicant
Creditor
For Creditor Use
Joint Applicant or Other Party
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lll
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lll
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"You" et al "We"
Check only one of the two types:
(not living with you)(not living with you)
(describe):
(First, Middle, Last) (First, Middle, Last)Full Name
Applicant Information
Loan Type
Signature Loan Car Loan RV/Boat/ATV Loan
Overdraft Protection CD Loan Real Estate
Construction Home Equity Commercial
,
*
-
VMPC148 (1211).00
UCA 11/1/2012
Page 1 of 4
VMP
Universal Credit Application
1986, 2012Wolters Kluwer Financial Services
Custom MDF. EARUCA1Bankers Systems
Credit Application
Important Information to Applicant(s).
What this means for you.
Security for CreditLoan Purpose
First Payment Date
Proceeds of Credit to Be Used for
Repayment Interval
$
Previous Address
Primary Phone
No. of Months
Credit Type
Amount Financing Type
Gov't ID Type Gov't ID No. Gov't ID Issued By
Gov't ID Issue Date Gov't ID Exp. Date Date of Birth
Soc. Sec. No.
Email Address:
Present Address
Second Phone
Application Date
Joint Credit -Individual Credit -
Nearest Relative
Your Relationship to us (or our affiliate)
Dependents
Full Name
Previous Address
Primary Phone
Have you ever received credit from us?
Gov't ID Type Gov't ID No. Gov't ID Issued By
Gov't ID Issue Date Gov't ID Exp. Date Date of Birth
Soc. Sec. No.
Email Address:
Present Address
Second Phone
Nearest Relative
Your Relationship to us (or our affiliate)
Dependents
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 applies for a loan or opens an account.
When you apply for a loan or 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. In some instances,
we may use outside sources to confirm the information. The information
you provide is protected by our privacy policy and federal law.
Account No. Class No. Date Received
Name:
Address:
Telephone:
( means Applicant, ; and means Creditor)
Monthly
Joint ApplicantApplicant
By initialing below, you intend to apply for "joint credit".You are relying solely on your income or assets.
To purchase property that will secure your credit
To purchase property that is a residential dwelling and is not real estate
To finance home improvements to a residential dwelling
Other
New
Refinance
Line of Credit
Loan
Sale
Lease
Agricultural
Business
Consumer
Unsecured
Secured
Insider (Shareholder, Director, Officer)
No. of Yrs.:
EmployeeNone
Own
Ages:
Rent
Own Rent No. of Yrs.:
No.:
CellCell
Name:
Address:
Telephone:
Insider (Shareholder, Director, Officer)
office/branch:
No. of Yrs.:
If yes, when:
EmployeeNone
Own
Yes
Cell
Ages:
Rent
Own Rent
No
No. of Yrs.:
No.:
CellCell Cell
Read each instruction carefully before completing this form.
Type of Requested Credit
Type of Application
Applicant
Creditor
For Creditor Use
Joint Applicant or Other Party
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l
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l
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lll
l
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l
l
l
l
l
l
l
l
lll
l
l
lll
l
l
l
l
l
"You" et al "We"
Check only one of the two types:
(not living with you)(not living with you)
(describe):
(First, Middle, Last) (First, Middle, Last)Full Name
Applicant Information
Loan Type
Signature Loan Car Loan RV/Boat/ATV Loan
Overdraft Protection CD Loan Real Estate
Construction Home Equity Commercial
Line of Credit Open End Line of Credit
Loan Purpose
IS ANY OF THIS INCOME LIKELY TO BE REDUCED
BEFORE THE CREDIT REQUEST IS PAID OFF?
HAVE YOU DECLARED BANKRUPTCY IN THE PAST 14
YEARS?
ARE THERE ANY UNSATISFIED JUDGEMENTS AGAINST
YOU?
ARE YOU A CO-MAKER, ENDORSER OR
GUARANTOR ON ANY LOAN OR CONTRACT?
APPLICANT CO-APPLICANT
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
WHERE FILED?
WHEN?
TO WHOM?
FOR WHOM?
Credit History
Insurance Disclosure
,
*
-
VMPC148 (1211).00
UCA 11/1/2012
Page 4 of 4
VMP
1986, 2012
Bankers Systems
Universal Credit Application
Wolters Kluwer Financial Services
MDF. EARUCA1
10. Additional Information or Explanations
9. Marital Status
11. Notices
Mortgage Loan Originator Information
For Creditor Use
Married
Separated
Unmarried
The Ohio laws against discrimination require all creditors make credit equally available to all creditworthy 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.
Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim
containing a false or deceptive statement is guilty of insurance fraud.
Married
Separated
Unmarried
If checked, You further agree that you have signed this with one or more electronic signatures. You
Notice to Married Applicants. No provision of any marital property agreement, unilateral statement under Wisc. Statutes
§ 766.59 or a court decree under Wisc. Statutes § 766.70 adversely affects the interests of the Creditor unless the Creditor, prior to the time the
credit is granted, is furnished a copy of the agreement, statement or decree or has actual knowledge of the adverse provision when the obligation
to the Creditor is incurred.
For Married Wisconsin Residents. The credit being applied for, if granted, will be incurred in the interest of my marriage or family. I understand
the Creditor may be required by law to give notice of this transaction to my spouse.
A consumer report may be ordered in connection with your application. Upon your request, we will inform you whether or
not a report was ordered. If a report was ordered, we will tell you the name and address of the consumer reporting agency that provided the
report. Subsequent reports may be ordered or utilized in connection with an update, renewal or extension of credit for which you have applied.
The owner of the homestead is not required to apply the proceeds of the extension of credit to repay another debt except debt
secured by the homestead or debt to another lender.
Each applicant, if married, may apply for a separate account.
You authorize us to contact you using any of the telephone numbers listed on this Credit Application or that you subsequently provide us in
connection with your credit account - regardless whether the number we use is assigned to a paging service, cellular telephone service,
specialized mobile radio service, other radio common carrier service or any other service for which you may be charged for the call. You further
authorize us to contact you through the use of voice, text and email and through the use of prerecorded/artificial voice messages or an automatic
dialing device.
Notice: It is a federal crime punishable by fine, imprisonment, or both, to knowingly make any false statements concerning any of the above facts
as applicable under the provisions of Title 18, United States Code § 1001,
intend your electronic signature to have the effect of your written ink signature. You viewed and read the entire and notices
before you signed it. You received a paper copy of this after it was signed. You understand that this is in
the electronic form that we will keep. We may rely on, and enforce, this in the electronic form or as a paper version of the
electronic form.
If this is secured by a consumer's residential dwelling that is owned by you, we may be required under federal or state law to
disclose our mortgage loan origination identification number(s), which are as follows, if applicable:
Mortgage Loan Originator Name and Identifier:
Mortgage Loan Origination Company Name and Identifier:
You certify that everything you have stated in this Credit Application and on any other documents submitted to us are true and correct to the best
of your knowledge. You understand that you must update the information contained in this Credit Application if either your financial condition
materially changes or we make a request to you orally or in writing. You understand that we will retain this Credit Application whether or not it is
approved.
You authorize us to request one or more consumer reports, to check and verify your credit and employment history, and to answer questions
others may ask us about our credit experience with you.
(as defined by state law; incl. domestic partnership, civil union)
(including single, divorced, widowed)
(as defined by state law; incl. domestic partnership, civil union)
(including single, divorced, widowed)
(if applicable)
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l
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Ohio Residents.
Electronic Signature.
Wisconsin Residents.
New York Residents.
Texas Residents.
California Residents.
DateDateApplicant Signature Joint Applicant, or Other Party, Signature
Reason Code(s)Date Received Received By Date Action Taken Action Taken By Action Taken
Leave blank
or
or
Leave blank
or
or
, unless:
(1) the credit will be secured,
(2) you reside in a community property state,
(3) you are relying on property, located in a community property
state, as a basis for repayment.
Credit Application
, unless:
(1) the credit will be secured,
(2) you reside in a community property state,
(3) you are relying on property, located in a community property
state, as a basis for repayment.
et seq.
Credit Application
Credit Application Credit Application
Credit Application
Credit Application
Applicant Joint Applicant or Other Party
}
}
�Certifications, Authorizations and Signatures
,
*
-
VMPC148 (1211).00
UCA 11/1/2012
Page 4 of 4
VMP
1986, 2012
Bankers Systems
Universal Credit Application
Wolters Kluwer Financial Services
MDF. EARUCA1
10. Additional Information or Explanations
9. Marital Status
11. Notices
Mortgage Loan Originator Information
For Creditor Use
Married
Separated
Unmarried
The Ohio laws against discrimination require all creditors make credit equally available to all creditworthy 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.
Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim
containing a false or deceptive statement is guilty of insurance fraud.
Married
Separated
Unmarried
If checked, You further agree that you have signed this with one or more electronic signatures. You
Notice to Married Applicants. No provision of any marital property agreement, unilateral statement under Wisc. Statutes
§ 766.59 or a court decree under Wisc. Statutes § 766.70 adversely affects the interests of the Creditor unless the Creditor, prior to the time the
credit is granted, is furnished a copy of the agreement, statement or decree or has actual knowledge of the adverse provision when the obligation
to the Creditor is incurred.
For Married Wisconsin Residents. The credit being applied for, if granted, will be incurred in the interest of my marriage or family. I understand
the Creditor may be required by law to give notice of this transaction to my spouse.
A consumer report may be ordered in connection with your application. Upon your request, we will inform you whether or
not a report was ordered. If a report was ordered, we will tell you the name and address of the consumer reporting agency that provided the
report. Subsequent reports may be ordered or utilized in connection with an update, renewal or extension of credit for which you have applied.
The owner of the homestead is not required to apply the proceeds of the extension of credit to repay another debt except debt
secured by the homestead or debt to another lender.
Each applicant, if married, may apply for a separate account.
You authorize us to contact you using any of the telephone numbers listed on this Credit Application or that you subsequently provide us in
connection with your credit account - regardless whether the number we use is assigned to a paging service, cellular telephone service,
specialized mobile radio service, other radio common carrier service or any other service for which you may be charged for the call. You further
authorize us to contact you through the use of voice, text and email and through the use of prerecorded/artificial voice messages or an automatic
dialing device.
Notice: It is a federal crime punishable by fine, imprisonment, or both, to knowingly make any false statements concerning any of the above facts
as applicable under the provisions of Title 18, United States Code § 1001,
intend your electronic signature to have the effect of your written ink signature. You viewed and read the entire and notices
before you signed it. You received a paper copy of this after it was signed. You understand that this is in
the electronic form that we will keep. We may rely on, and enforce, this in the electronic form or as a paper version of the
electronic form.
If this is secured by a consumer's residential dwelling that is owned by you, we may be required under federal or state law to
disclose our mortgage loan origination identification number(s), which are as follows, if applicable:
Mortgage Loan Originator Name and Identifier:
Mortgage Loan Origination Company Name and Identifier:
You certify that everything you have stated in this Credit Application and on any other documents submitted to us are true and correct to the best
of your knowledge. You understand that you must update the information contained in this Credit Application if either your financial condition
materially changes or we make a request to you orally or in writing. You understand that we will retain this Credit Application whether or not it is
approved.
You authorize us to request one or more consumer reports, to check and verify your credit and employment history, and to answer questions
others may ask us about our credit experience with you.
(as defined by state law; incl. domestic partnership, civil union)
(including single, divorced, widowed)
(as defined by state law; incl. domestic partnership, civil union)
(including single, divorced, widowed)
(if applicable)
l
l
l
l
Electronic Signature.
Wisconsin Residents.
New York Residents.
Texas Residents.
California Residents.
DateDateApplicant Signature Joint Applicant, or Other Party, Signature
Reason Code(s)Date Received Received By Date Action Taken Action Taken By Action Taken
Leave blank
or
or
Leave blank
or
or
, unless:
(1) the credit will be secured,
(2) you reside in a community property state,
(3) you are relying on property, located in a community property
state, as a basis for repayment.
Credit Application
, unless:
(1) the credit will be secured,
(2) you reside in a community property state,
(3) you are relying on property, located in a community property
state, as a basis for repayment.
et seq.
Credit Application
Credit Application Credit Application
Credit Application
Credit Application
Applicant Joint Applicant or Other Party
}
}
�Certifications, Authorizations and Signatures
Certications, Authorizations and Signatures
Date Application Received _________________________________________ Loan Officer Name (Print) _________________________________________
Loan Officer NMLS #____________________________________________________Loan Officer Signature ____________________________________________
Bank Name & Location ___________________________________________________________________________________________________________________
City_________________________________ State _________ Zip ___________
Bank Telephone #_________________________________________________
Bank NMLS # 677399
Address
TrailWest Bank
TrailWest Bank.
TrailWest Bank’s
DO NOT EMAIL! FILL OUT AND RETURN TO BANK.
