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CREDIT APPLICATION

We are making changes in our "Credit application"
It will be up shortly

IMPORTANT: read these Directions before completing this application.

Check
Appropriate
box		 If you are applying for individual credit in your own name, are not married, and are relying on alimony, child support, or separate maintenance payments or on the income or assets of another person as the basis for repayment of the credit requested, complete only Sections A and D. If the requested credit is to be secured, also complete Section E.
In all other situations, complete all Sections except E, providing information in B about your spouse, a joint applicant or user, or person on whose alimony, support, or maintenance payments or income or assets you are relying. If the requested credit is to be secured, also complete Section E.

Amount Requested:   Payment Date Desired:

Proceeds of Credit To be Used For:

SECTION A - INFORMATION REGARDING APPLICANT

Full Name (Last, First, Middle): Birthdate:

Present Street Address: Years There:

City: State: Zip: Telephone:

Social Security No: Driver's License No:

Previous Street Address: Years There:

City: State: Zip:

Present Employer: Years There: Telephone:

Position or title: Name of supervisor:

Employer's Address:

Previous Employer: Years There:

Previous Employers Address:

Present net salary or commission: $ Per: No. Dependents:

Dependents ages:

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

Other income: $ per: Source(s) of other income:

Is any income listed in this Section likely to be reduced in the next two years or before the credit requested is paid off?  Yes (Explain in detail). No

If you chose yes, please explain in detail in the box below:

Have you ever received credit from us? When? Office:

Checking Account No: Institution and Branch:

Savings Account No: Institution and Branch:

Name of nearest relative not living with you: Telephone:

Relationship: Address:

SECTION B - INFORMATION REGARDING SPOUSE, JOINT APPLICANT, USER, OR OTHER PARTY.

Full Name (Last, First, Middle): Birthdate:

Relationship to applicant (if any):

Present Street Address: Years There:

City: State: Zip: Telephone:

Social Security No: Driver's License No:

Present Employer: Years There: Telephone:

Position or title: Name of supervisor:

Employer's Address:

Previous Employer: Years There:

Previous Employers Address:

Present net salary or commission: $ Per: No. Dependents:

Dependents ages:

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

Other income: $ per: Source(s) of other income:

Is any income listed in this Section likely to be reduced in the next two years or before the credit requested is paid off?  Yes (Explain in detail). No

If you chose yes, please explain in detail in the box below:

Checking Account No: Institution and Branch:

Savings Account No: Institution and Branch:

Name of nearest relative not living with spouse, Joint Applicant, User, or other Party:

Relationship: Address:

SECTION C - MARITAL STATUS

Applicant: Married   Separated   Unmarried (including single, divorced, and widowed)

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

SECTION D - ASSET AND DEPT INFORMATION (if Section B has been completed, this Section should be completed giving information about both the applicant and Spouse, Joint applicant, User, or Other Person. Please mark Applicant-related information with an "A in the beginning of the box you put the information. If Section B was not completed, Only give information about the Applicant in this Section.)

ASSETS OWNED

Description of Assets Value Subject to Dept?
Yes/No		 Name(s) Owner(s)
   Cash:
   		$    yes  no
   Auto (make, model, year)
   		$    yes  no
   Cash Value of Life Ins. (Issuer, Face Value)
   		$    yes  no
  Marketable Securities (Issuer, Type, No. of Shares)
 		 $    yes  no
  Real Estate (location, Date Acquired)
 		 $    yes  no
Other (List):
 $    yes  no
Total Assets:
$		 $    yes  no

ALL OUTSTANDING DEBTS (include charge accounts, installment contracts, credit cards, rent mortgages, etc. Use separate sheet if necessary.)

Name of Creditor Value Subject to Debt?
Yes/No		 Original
Debt		 Present
balance		 Monthly
Payments		 Past Due
Yes/No
1. Landlord or Mortgage Holder:
 $   yesno $ $  $ yesno
2.
 $   yesno $ $  $ yesno
3.
 $   yesno $ $  $ yesno
4.
 $   yesno $ $  $ yesno
5.
 $   yesno $ $  $ yesno
6.
 $   yesno $ $  $ yesno
7.
 $   yesno $ $  $ yesno
8.
 $   yesno $ $  $ yesno
9.
 $   yesno $ $  $ yesno
10.
 $   yesno $ $  $ yesno
11.
 $   yesno $ $  $ yesno
12.
 $   yesno $ $  $ yesno
13.
 $   yesno $ $  $ yesno
14.
 $   yesno $ $  $ yesno
15.
 $   yesno $ $  $ yesno

Are you a co-maker, endorser or
guarantor on any loan or contract? yesno 

If "Yes" for whom? To Whom?

Are there any unsatisfied judgments against you?
yesno  If "Yes amount:$ If "Yes" to whom owed?

Have you been declared
bankrupt in the last 14 years? yesno  If "Yes" Where?
Year you declared bankruptcy:

OTHER OBLIGATIONS (E.G., Liablility, child support, separate maintenance. use the box below to enter the obligations and explain.

Everything that I have stated in this application is correct to the best of my knowledge. I understand that you will retain this application whether or not it is approved. You are authorized to check my credit and employment history and to answer questions about your credit experience with me.

By typing your full name in the box below you are aware that you have done the same as if you signed a contract in our presence. You are also aware this is legal and binding.

applicant's Signature:

Date Signed:

Other Signature (Where applicable)

Date Other Signature Was Signed: