Consumer Credit Application

Type of Credit Requested 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, including community property Joint Credit - We intend to apply for joint credit Initials Joint Initials Amount Requested For How Long Payment Date Desired Desired Repayment Proceeds of Loan to Be Used For Monthly Other

For Creditor Use Only Date     Account No     Approved Declined By

Section A - Individual Applicant Information

Name (First, Middle, Last)				Birth Date		Telephone Number
Email Address				Cell Phone Number
Driver's License No		Social Security Number		Number of Dependents		Ages of Dependents
Address (Street, City, State, & ZIP)				County		Do you Own or Rent	How Long
Previous Address (Street, City, State, & ZIP) (Complete if less than 3 yrs at current address)
				County		Did you Own or Rent	How Long
Employer (Company Name & Address)							How Long
Business Phone		Position or Title		Salary / 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 $
Is any income listed in this section likely to be reduced before the credit requested is paid off?					Have you previously received credit from us?
No Yes (Explain)					No Yes (When)
Name & address of nearest relative not living with you				Relationship			Telephone

Section B - Joint Applicant or Other Party Information

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 (First, Middle, Last)				Birth Date		Telephone Number
Email Address				Cell Phone Number
Driver's License No		Social Security Number		Number of Dependents		Ages of Dependents
Address (Street, City, State, & ZIP)				County		Do you Own or Rent	How Long
Previous Address (Street, City, State, & ZIP) (Complete if less than 3 yrs at current address)
				County		Did you Own or Rent	How Long
Employer (Company Name & Address)							How Long
Business Phone		Position or Title		Salary / 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 $
Is any income listed in this section likely to be reduced before the credit requested is paid off?					Have you previously received credit from us?
No Yes (Explain)					No Yes (When)
Name & address of nearest relative not living with you				Relationship			Telephone

Section C - Marital Status

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 (includes single, divorced and widowed)
Other Party	Married Separated Unmarried (includes single, divorced and widowed)

Section D - Assets & Debt Information

If Section B has been completed, this section should be completed giving information about both the Applicant and Joint Applicant or Other Person.
Please mark Applicant-related information with an "A". If Section B was not completed, only give information about the Applicant in this section.

Assets Owned

(Use a separate sheet if necessary.)

Description of Assets		Name in Which the Account is Carried	Subject to Debt? Yes/No	Value
Checking Account Number(s)	Name of Financial Institution			$
Savings Account Number(s)	Name of Financial Institution
Certificate of Deposit(s)	Name of Financial Institution
Marketable Securities - Issuer	Type, no. of shares
Real Estate (homestead, rental, other)	Address
Life Insurance - Issuer	Face value
Automobiles - Make	Model, year
Other
Total Assets				$

Outstanding Debts

(Include charge accounts, installment contracts, credit cards, rent, mortgages and other obligations.  Use separate sheet if necessary.)

Creditor	Account Number	Name in Which the Account is Carried	Original Amount	Present Balance	Monthly Payments
Landlord or Mortgage Holder	Rent Payment Mortgage		(Omit Rent) $	(Omit Rent) $	$
Automobiles (describe)
Other
Total Debts			$	$	$

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 owed?		Amount $
Have you been declared bankrupt in the last 10 years?	No Yes	if yes, where?		Year?

Signatures -

I certify that everything I have stated in this application and on any attachments is correct. Lender may keep this application whether or not it is approved. By signing below I authorize Lender to check my credit and employment history and to answer questions others may ask Lender about my credit record with Lender. I understand I must update credit information at Lender's request if my financial condition changes.

Applicant's Signature	Date	Other Signature (Where Applicable)	Date