Auto/Personal Loan Application

* Required Field

Loan Information
Purpose *
 Amount Requested *
 Loan Term *
Detailed Description of Collector Car or Reason for Personal Loan
Year
 Make
 Model
 VIN/SN
 Mileage
(put n/a if not applicable)

Personal Information
First Name *
 MI
Last Name *
 Social Security Number *
Street Address *
 City *
State *
 Zip Code *
Telephone Number *
 Birthdate (Month/Day/Year) *
 E-mail Address

Housing Information
Length of Residence *
 years  months
Housing Status *
 Monthly Payment *
Mortgage Holder
 Estimated Property Value
 Mortgage Balance

Employment Information
Employer
 Telephone Number
 Supervisor
Street Address
 City
State
 Zip Code
Position/Department
 Length of Employment
 years  months
Income
 Per

Financial Information
Do you have a Checking Account?
 Yes  No
Checking Account Number
 Financial Institution
Do you have a Savings Account?
Yes No
Savings Account Number
 Financial Institution

References
Name of a Relative
 Relationship to Applicant
 Telephone Number
Street Address
 City
State
 Zip Code
Name of a Personal Friend
 Telephone Number
Street Address
 City
State
 Zip Code


Click here to access the Co-Applicant section or Click "Submit" to finish!

*Please Note: Alimony, child support, or maintenance income need not be revealed if you do not wish it to be
considered as a basis for repaying this obligation.

Submission of this form authorizes Heartland Tri-State Bank to verify information provided herein,
including but not limited to employment credit history.