LOAN INFORMATION: (fill out in full)

AMOUNT OF LOAN REQUEST:  $

PURPOSE:

PERSONAL INFORMATION: (required)

FULL NAME:                EMAIL ADDRESS:

DATE OF BIRTH:

MARITAL STATUS:MARRIEDUNMARRIEDSEPARATED

SOCIAL SECURITY #:   # OF DEPENDENTS:

ADDRESS:  CITY:  STATE:

ZIP CODE:                     HOME PHONE:

BUYINGRENTING         MORTGAGE HOLDER/LANDLORD:

PAYING PER MONTH:  $

EMPLOYER'S NAME:             HOW LONG:

POSITION & DEPARTMENT:

SALARY PER MONTH:  $  BUSINESS PHONE:

CO-APPLICANT OR OTHER PERSON: (optional)

FULL NAME:                DATE OF BIRTH:

SOCIAL SECURITY #:

ADDRESS:  CITY:  STATE:

ZIP CODE:         HOW LONG AT ADDRESS:

EMPLOYER NAME:      EMPLOYER ADDRESS:

HOW LONG:         SALARY PER MONTH:  $

BUSINESS PHONE:

AGREEMENT: (required)

HAVE YOU EVER BEEN ADJUDICATED A BANKRUPT, MADE A SETTLEMENT WITH CREDITORS, OR IF YOU HAVE ANY SUITS, JUDGMENTS, GARNISHMENTS OR OTHER LEGAL PROCEEDINGS AGAINST YOU?

 NOYES           IF YES PLEASE EXPLAIN:

I AGREE TO NOTIFY THE COMPANY OF ANY MATERIAL CHANGE IN THE ABOVE STATEMENT.  I AUTHORIZE THE COMPANY TO OBTAIN SUCH INFORMATION AS THE COMPANY MAY REQUIRE CONCERNING THE STATEMENTS MADE IN THIS APPLICATION AND AGREE THAT THE APPLICATION SHALL REMAIN IN THE COMPANY PROPERTY WHETHER OR NOT THE LOAN IS GRANTED.  I, THE ABOVE NAMED APPLICANT HEREBY DECLARE THE FOREGOING STATEMENT IS TRUE IN EVERY RESPECT.  I UNDERSTAND THAT AN INVESTIGATION MAY BE MADE WHEREBY THAT INFORMATION MAY BE OBTAINED THROUGH PERSONAL INTERVIEWS WITH MY NEIGHBORS, FRIENDS OR OTHERS WITH WHOM I AM ACQUAINTED.  THIS INQUIRY MAY INCLUDE INFORMATION AS TO MY CHARACTER, GENERAL REPUTATION, PERSONAL CHARACTERISTICS, AND MODE OF LIVING.  I FURTHER UNDERSTAND THAT I HAVE THE RIGHT TO MAKE A WRITTEN REQUEST WITHIN A REASONABLE PERIOD OF TIME TO RECEIVE ADDITIONAL DETAILED INFORMATION ABOUT THE NATURE AND SCOPE OF THIS INVESTIGATION.  ANY WILLFUL MISREPRESENTATION ON THIS STATEMENT COULD RESULT IN A FINE AND/OR IMPRISONMENT UNDER THE PROVISION OF THE U.S. CRIMINAL CODE.

I AGREE WITH THIS STATEMENT.

I DO NOT AGREE WITH THIS STATEMENT.

DATE:                 NAME OF APPLICANT: