CREDIT APPLICATION
SECTION A - INDIVIDUAL APPLICANT INFORMATION
SECTION B - JOINT APPLICANT OR OTHER PARTY INFORMATION
SECTION C - MARITAL STATUS
AMOUNT REQUESTED
$
FOR HOW LONG PAYMENT DATE DESIRED WANT TO REPAY
MONTHLY
PROCEEDS OF LOAN TO BE USED FOR:
DATE CLASS NO.
ACCOUNT NO.
APPROVED BY
DECLINED BY
FOR CREDITOR USE
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
JOINT CREDIT - We intend to apply for joint credit. (initials)
other sources
IMPORTANT: Check ( ) the appropriate boxes below and complete the applicable sections.
Complete only if: for joint credit, for individual credit relying on income or assets from other sources, or applicant is married and resides in a community property state.
NAME (Last, First, Middle)
BIRTHDATE
ADDRESS (Street, City, State & Zip)
PREVIOUS ADDRESS (Street, City, State & Zip) (Complete if less than 3 years at present address)
EMPLOYER (Company Name & Address)
BUSINESS PHONE Ext.
PREVIOUS EMPLOYER (Company Name & Address)
NAME AND ADDRESS OF NEAREST RELATIVE NOT LIVING WITH YOU RELATIONSHIP TELEPHONE NO. (Include Area Code)
SOURCES OF OTHER INCOME
Is any income listed in this Section likely to be reduced before the credit request is paid off?
TELEPHONE NO. DRIVER'S LICENSE NO. SOCIAL SECURITY NO. NO. DEPENDENTS AGES OF DEPENDENTS
COUNTY
COUNTY
HOW LONG
HOW LONG
HOW LONG
Do you own
or rent?
Did you own
or rent?
POSITION OR TITLE
SALARY PER MONTH
GROSS: $ NET: $
AMOUNT PER MONTH
$
Have you previously received credit from us?
No Yes - When?
AGES OF DEPENDENTSNO. DEPENDENTS
HOW LONG
HOW LONG
HOW LONG
HOW LONG
SOCIAL SECURITY NO.DRIVER'S LICENSE NO.
PRESENT ADDRESS (Street, City, State & Zip)
POSITION OR TITLE
AMOUNT PER MONTH
$
NAME (Last, First, Middle)
BIRTHDATE
RELATIONSHIP TO APPLICANT (If Any)
EMPLOYER (Company Name & Address)
BUSINESS PHONE Ext.
PREVIOUS EMPLOYER (Company Name & Address)
SOURCES OF OTHER INCOME
Is any income listed in this Section likely to be reduced before the credit requested is paid off?
TELEPHONE NO.
Has Joint Applicant or Other Party ever received credit from us?
No Yes - When?
Complete only if: for joint or secured credit, or applicant resides in a community property state or is relying
on property located in such a state as a basis for repayment of the credit requested.
APPLICANT Married Separated Unmarried (including single, divorced, and widowed)
OTHER PARTY Married Separated Unmarried (including single, divorced, and widowed)
No Yes (Explain)
Alimony, child support, separate maintenance received under: Court Order Written Agreement Oral Understanding
No Yes (Explain)
Alimony, child support, separate maintenance received under: Court Order Written Agreement Oral Understanding
GROSS: $ NET: $
SALARY PER MONTH
Federal law requires financial institutions to obtain sufficient information to verify your identity. You may be asked several
questions and to provide one or more forms of identification to fulfill this requirement. 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.
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TYPE OF CREDIT REQUESTED
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 income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.
IMPORTANT APPLICANT INFORMATION:
(page 1 of 2)
1986 Bankers Systems, Inc., St. Cloud, MN Form UCA 6/30/2003
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