Credit Application

IMPORTANT: Please read these directions before completing this Application, and check the appropriate box below.

Section A - Information Regarding Applicant

Referred by

Applicant Comments Comments

Applicant Full Name Name (Last, First, MI) *

Applicant DOB Date of Birth MM/DD/YYYY *

Applicant SSN Social Security Number *

Applicant Present Address Present Address *

Applicant Present City City *

Applicant Present State State *

Applicant Present Zip Zip *

Applicant Phone Phone *

Applicant How long at present address? How long at present address? *

Applicant Previous Address Previous Address

Applicant How long at previous address? How long at previous address?

Applicant Present Employer Present Employer (Company Name & Address) *

Applicant How long with present employer? How long with present employer? *

Applicant Position or title Position of Title *

Applicant Name of Supervisor Name of Supervisor *

Applicant Business Phone Business Phone & Ext. *

Applicant Previous employer Previous Employer

Applicant How long with previous employer? How long with previous employer?

Applicant Gross Salary Gross Salary/Commis. *

Applicant Net Salary Net Salary/Commis. *

Applicant Number of dependents # of Dependents

Applicant Ages of dependents Ages of Dependents

Alimony, child support, or separate maintenance income need not be revealed if you do not wish to have.

Alimony, child support, separate maintenance

Court Order Written Agreement Oral Understanding

Applicant Other Income

Other Income

Sources of Other Income

Total $

Have you ever received credit from us? Yes No

Applicant Checking and Savings account info

Checking Account Number

Where?

Savings Account Number

Where?

Applicant Relatives

Name & Address of nearest Relative not living with you

Relationship

Phone

Name & Address of nearest Relative not living with you

Relationship

Phone

Section B - Information Regarding Joint Applicant or Other Party

Joint Applicant full name Name (Last, First, MI)

Joint DOB Date of Birth MM/DD/YYYY

Joint SSN Social Security Number *

Relationship to Applicant (if any)

Joint Present Address Present Address *

Joint city City *

Joint state State *

Joint zip Zip *

Joint phone Phone *

Joint how long at present address? How long at present address? *

Joint present employer Present Employer (Company Name & Address) *

Joint phone Phone

Joint how long with present employer? How long with present employer? *

Joint title Position or Title *

Joint name of supervisor Name of Supervisor *

Joint business phone Business Phone *

Joint position or title Position of Title

Joint name of supervisor Name of Supervisor

Joint Business phone Business Phone & Ext.

Joint previous employer Previous Employer (Company Name & Address)

Joint how long with previous employer? How long with previous employer?

Joint gross salary Gross Salary/Commis. *

Joint net salary Net Salary/Commis. *

Joint number of dependents # of Dependents

Joint Ages of Dependents Ages of Dependents

Alimony, child support, or separate maintenance income need not be revealed if you do not wish to have.

Alimony, child support, separate maintenance

Court Order Written Agreement Oral Understanding

Joint Other Income

Other Income $

Sources of Other Income

Is any income listed in this Section likely to be reduced before the credit requested is paid?

No Yes Explain Explain reduced income

Have you ever received credit from us? Yes No

Joint Checking and Savings Accounts

Checking Account Number

Where?

Savings Account Number

Where?

Joint relatives

Name & Address of nearest Relative not living with you

Relationship

Phone

Section C - Marital Status (Do not complete if this is an Application for individual unsecured credit).

Section D - Asset & 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. If Section B was not completed, only give information about the Applicant in this section.

Assets Owned

Cash $

Subject to Debit? Yes/No

Name of Owners

Automobiles

Make

Model

Year

+ Add Automobiles

Cash Value of Life Insurance

Issuer

Face Value

Real Estate

Location

Date Acquired

Marketable Securities

Issuer

Type

# of Shares

Other

List

Total Assets

Outstanding Debts (Include charge accounts, installment contracts, credit cards, rent, mortgages, etc. Use separate sheet if necessary).

Creditor

Landlord of Mortgage Holder

Name in which account is

Monthly Payments $

Type of Debt

Rent Payment Mortgage

Original Debt $

Present Balance $

Auto Insurance Agency Name

Auto Insurance Agency Address

+ Add another outstanding debt

Credit References (Paid off Accounts)

Landlord of Mortgage Holder

Type of Debt

Credit Rent Payment Mortgage

Name in which account is

Original Debt $

Present Balance $

Monthly Payments $

Past Due? Yes/No

Auto Insurance Agency (Name & Address)

Driver’s License

State

Name in which account is

Original Debt $

Present Balance $

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

No Yes, For Whom? Yes for whom

Have you declared bankruptcy in the last 10 years?

No Yes. Where? What Year? Bankruptcy more info

Other Obligations (For example, liability to pay alimony, child support, separate maintenance).

Section E - Secured Credit

The lender may not condition an extension of credit on either: (1) My purchase of an insurance product or annuity from the lender of any of it's affiliates; or (2) My agreement not to obtain, or a prohibition on me from obtaining, an insurance product of annuity from an unaffiliated entity. Everything that I have stated in this application is corrected 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. I further acknowledge that I have received the disclosures described in Section F.

By clicking Submit below, I certify that everything I have stated in this application is correct. Citizens Bank Minnesota may keep this application whether or not it is approved. By submitting this application I authorize Citizens Bank Minnesota to check my credit and employment history and to answer questions others may ask Citizens Bank Minnesota about my credit record with Citizens Bank Minnesota. I understand that I must update credit information at Citizens Bank Minnesota request if my financial condition changes.

THE LENDER MAY NOT CONDITION AN EXTENSION OF CREDIT ON EITHER:
1) My purchase of an insurance product of annuity from the lender of any of its affiliates; or
2) My agreement not to obtain, or a prohibition on me from obtaining, an insurance product or annuity from an unaffiliated entity.

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Section A - Information Regarding Applicant

Section B - Information Regarding Joint Applicant or Other Party

Section C - Marital Status (Do not complete if this is an Application for individual unsecured credit).

Section D - Asset & Debt Information

Assets Owned

Automobiles

Cash Value of Life Insurance

Real Estate

Marketable Securities

Other

Total Assets

Outstanding Debts (Include charge accounts, installment contracts, credit cards, rent, mortgages, etc. Use separate sheet if necessary).

Creditor

Credit References (Paid off Accounts)

Section E - Secured Credit

If vehicle, please complete

Submitted Successfully!

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