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Loan Application

Please provide all the requested information. When you have completed the form, press the Submit button to send your application. If necessary, we will contact you for additional information.

The items marked with (*) are required fields.

General Information
Marital Status: Complete marital status if this loan is for:
a. Joint or secured credit, or
b. You reside in or rely on property located in a Community Property State. (AZ, CA, ID, LA, NM, NV, TX, WA, WI)
emptycheckbox Unmarried
emptycheckbox Married
emptycheckbox Separated
emptycheckbox This application is not for joint or secured credit and I do not live in the states listed above.
*Type of Loan Requested
*Loan Amount Requested $
*Loan Term Requested

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Primary Applicant
*Credit Intention I intend to apply for credit.
*Account Number
*Last Name
*First Name
Middle Name
*Social Security Number (TIN)
*Date of Birth
Number of Dependents
Ages of Dependents
*Home Phone Number
Work Phone Number ext.
emptycheckbox Cell emptycheckbox Phone emptycheckbox Pager emptycheckbox Other Phone Number ext.
Email Address
Drivers License #
Drivers License State
Mother’s Maiden Name
Home Address
*Address 1
Address 2
*City
*State
*Zip
Time at Current Residence Years Months
Residence Type emptycheckbox Own emptycheckbox Rent emptycheckbox Other
Monthly Payment $
Previous Address
Address 1
Address 2
City
State
Zip
Time at Previous Residence Years Months
Residence Type emptycheckbox Own emptycheckbox Rent emptycheckbox Other
Present Employer
Name
Phone Number ext.
Employment Status emptycheckbox Full Time emptycheckbox Part Time emptycheckbox Temp emptycheckbox Retired emptycheckbox Other
Job Title
Job Start Date
Gross Salary $ Per emptycheckbox Year emptycheckbox Month emptycheckbox Hour
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.
Other Income $ Per emptycheckbox Year emptycheckbox Month emptycheckbox Hour
Other Income Source
Previous Employer
Name
Phone Number ext.
Employment Status emptycheckbox Full Time emptycheckbox Part Time emptycheckbox Temp emptycheckbox Retired emptycheckbox Other
Job Title
Job Start Date
Job End Date
Gross Salary $ Per emptycheckbox Year emptycheckbox Month emptycheckbox Hour

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Co-Applicant
Credit Intention I intend to apply for credit.
Account Number
Last Name
First Name
Middle Name
Social Security Number (TIN)
Date of Birth
Number of Dependents
Ages of Dependents
Home Phone Number
Work Phone Number ext.
emptycheckbox Cell emptycheckbox Phone emptycheckbox Pager emptycheckbox Other Phone Number ext.
Email Address
Drivers License #
Drivers License State
Home Address
Address 1
Address 2
City
State
Zip
Time at Current Residence Years Months
Residence Type emptycheckbox Own emptycheckbox Rent emptycheckbox Other
Monthly Payment $
Previous Address
Address 1
Address 2
City
State
Zip
Time at Previous Residence Years Months
Residence Type emptycheckbox Own emptycheckbox Rent emptycheckbox Other
Present Employer
Name
Phone Number ext.
Employment Status emptycheckbox Full Time emptycheckbox Part Time emptycheckbox Temp emptycheckbox Retired emptycheckbox Other
Job Title
Job Start Date
Gross Salary $ Per emptycheckbox Year emptycheckbox Month emptycheckbox Hour
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.
Other Income $ Per emptycheckbox Year emptycheckbox Month emptycheckbox Hour
Other Income Source
Previous Employer
Name
Phone Number ext.
Employment Status emptycheckbox Full Time emptycheckbox Part Time emptycheckbox Temp emptycheckbox Retired emptycheckbox Other
Job Title
Job Start Date
Job End Date
Gross Salary $ Per emptycheckbox Year emptycheckbox Month emptycheckbox Hour

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References
Nearest relative Not Living With You
Last Name
First Name
Relationship
emptycheckbox Cell emptycheckbox Phone emptycheckbox Pager emptycheckbox Other Phone Number ext.
Address 1
Address 2
City
State
Zip

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Debts/Monthly Payments
List all other debts (for example, auto
loans, credit cards, second mortgage, home assoc. dues, alimony, child support, child
care, medical utilities, auto insurance, IRS liabilities, etc.) Please use a separate line
for each credit card and auto loan.
Debts Monthly Payments
Credit Card $
$
$
$
$
$
$
$
$
$
$

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Secured Credit
Complete only if credit is to be secured. Briefly describe the property to be given as security.
Property Description
If vehicle, please complete.
Color
Model
Plate No.
Names and addresses of all co-owners of the property.

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Additional Information
How would you prefer to be contacted?
emptycheckbox Home Phone
emptycheckbox Work Phone
emptycheckbox Cell Phone
emptycheckbox Email Address
emptycheckbox Other
Which office would you like to close your loan at?
emptycheckbox St. Francis
emptycheckbox Blaine
emptycheckbox Anoka-Ramsey
emptycheckbox East Bethel
Special Instructions/Comments
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Income verification is required; other information may be required.

I certify that statements on this application are true and complete. I authorize any person, association, firm or corporation to furnish, on request of this Financial Institution, information concerning me or my affairs.(Sec. 1014, Title 18, U.S. Code makes it a Federal Crime to knowingly make a false statement on this application.)