First State Bank » Serving Shannon & Polo, IL

* Required Fields

CONSUMER LOAN APPLICATION

Please mark the type of credit you are asking for:

*Select One

INDIVIDUAL CREDIT - Unmarried Applicant : Complete only Section 1

JOINT CREDIT - Complete Sections 1 and 2, and Section 3 as applicable, then initial the following to apply for joint credit :

Applicant:

Co-Applicant:

Purpose of Loan:
Amount Requested: $

SECTION 1 - Applicant

Single

Married

Legally Separated

NAME* (Last, First Middle)

Are you a U.S. Citizen?*
YES NO

Street Address*

City*

State*

ZIP*

County*

Home Phone #*

Cell Phone #*

How long have you been at this address?

Last 4 of Social Security #*

Date of Birth*

Email Address*

Own/Rent?
Own Rent

Mortgage Holder/Landlord

Mortgage Balance

Monthly Payment w/Escrow

Employer

Employer
Phone

Position/
Title *

Employment Start
Date

Annual Gross Income

Hourly Pay Rate*

Other Source of Income

Gross Amount
per month

Are you affiliated with, or do you work for a business involved with Marijuana growing,dispensing,processing or manufacturing?*

YES

Do you expect to conduct overseas wires?*

YES

SECTION 2 - Co-Applicant

Single

Married

Legally Separated

NAME (Last, First Middle)

Are you a U.S. Citizen?
YES NO

Street Address

City

State

ZIP

County

Home Phone #

Cell Phone #

How long have you been at this address?

Last 4 of Social Security #

Date of Birth

Email Address

Own/Rent?
Own Rent

Mortgage Holder/Landlord

Mortgage Balance

Monthly Payment w/Escrow

Employer

Employer
Phone

Position/
Title

Employment Start
Date

Annual Gross Income

Hourly Pay Rate

Other Source of Income

Gross Amount
per month

Are you affiliated with, or do you work for a business involved with Marijuana growing,dispensing,processing or manufacturing?

YES

Do you expect to conduct overseas wires?

YES

Section 3 - Vehicles	*Year, Make, Model*	*Mileage*	*VIN #*	*If Financed - Balance*
Vehicle 1
Vehicle 2

This Statement is submitted to obtain credit and does not constitute a contract for the extension of credit. I(we) certify that all information herein is true and complete. I (we) also authorize the bank to verify or obtain any additional information the bank may deem necessay concerning my (our) credit standing - from credit bureaus, collection agencies, and other sources - for consideration for the loan applied for hereon, or for any other service offered by the bank. The bank may release information about it's credit experience with me (us) as permitted by law. I (we) understand that it may be 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 provision of Title 18, United States code, section 1014.


*Applicant Signature*	*Date*	*Co-Applicant Signature*	*Date*

FDIC

Equal Housing Lender

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