Apply Loan

Section A – Applicant

You are applying for individual credit or an individual account, in your own name, and are relying on your own income or assets and not the income or assets of another person as the If basis for repayment of the credit requested, complete only Sections A & B. If the requested credit or account is to be secured, also complete the first part of Section C.

Name (Please print full name)

Home Phone

Cell Phone

Present Street Address

How Long at this address:

City and State

ZIP

Amount of Loan Requested

Requested Term to Pay

Purpose of Loan

Collateral Offered: Year/Make/Model/Mileage

Have you ever applied to us for a loan?

Yes

No

If yes, when?

Social Security Number

Drivers License Number – State

Birth Date

Name address and relationship of two nearest relatives not living with you other than a present or former spouse

Section B – Income and Employment

You are applying for individual credit or an individual account, in your own name, and are relying on your own income or assets and not the income or assets of another person as the If basis for repayment of the credit requested, complete only Sections A & B. If the requested credit or account is to be secured, also complete the first part of Section C.

Present Employer

Employer Address

Business Phone

Position or Title

Date of Employment

Previous Employer and Address

Position or Title

Years Employed

Monthly Income

Other Income From Whom or Describe (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 Monthly Income 1

Total monthly Income

If you have chosen to disclose income from alimony, child support or separate maintenance, is such income pursuant to:

Written Agreement

Court Decree

Other

How Long Received?

How Often

From Whom

Section C – Joint Applicant, User or Other Party

If this Section of Application is completed, the indebtedness of Co-Applicant/Guarantor/Endorser must be shown under the "Liabilities and Indebtedness" Section above. (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)

Name and relationship to Applicant

Co-Applicant

Guarantor

Co-Signer

Endoser

Address

Employed By

How Long

Position or Title

Business Phone

Home Phone

Social Security Number

Birth Date

Monthly Income

Other Income

Total Income

Drivers License Number – State

Is any income listed in this Section likely to be reduced in the next two years or before the credit requested is paid off?

No

YesIf yes, explain in detail

Name, address and relationship of two nearest relatives not living with you other than a present or former spouse

Are you a U.S. Citizen?

Yes

No

My Principal Financial Institution is:

Signatures

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 loan is approved. You are authorized to check my credit and employment history and to answer questions about your credit experience with me.

Applicant Signature

Date

Co-applicant/Co-signer/Guarantor/Endorser Signature (Where Applicable)

Date

Important Information About Procedures for Opening a New Account

To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. What this means for you: When you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents.

Chickasaw Community Bank

Personal Loan Application

Section A – Applicant

Section B – Income and Employment

Section C – Joint Applicant, User or Other Party

Signatures

Important Information About Procedures for Opening a New Account

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