Personal Information
Last Name
 First
   Middle
 Optional
Social Security No.
 Birth Date
   Driver's License or State ID No.
 State
 Next Payday
Home Address
 Apt. #
   City
 State
 Zip
Do You:
Own     Rent     Other		 How long at current address?
Home Telephone Number
 Message, Phone, or Other Phone Number
 Email Address

Employment Information
Current Employer
 Address
 Full-time
Part-time
Work Phone #
 Extension
   Title
 How long at current job?
Paid:
Once a week Every 2 weeks
Once a month Twice a Month
Other 		Day of Week Paid
   Take Home Pay (after taxes)
 Do you have direct Deposit?

Banking / Check Information
Bank Name: Checking Account
 Checking Account #
   Checking Account Open How Long?
 Next check number
Bank Name: Savings Account
 Savings Account #
 Savings Account Open How Long?

Social Security and Pension Customers
Is your check direct deposited?
Yes No 		How much do you receive monthly?
 What day is the money posted to your account?

Spouse Information
Last Name
 First
 Middle
 Birth Date
 Social Security Number
Employer
 Address
 Work Phone #
 Title
 Full-time Part-time
 How Long?

Covered Borrower Identification Statement

Federal law provides important protections to active duty military members of the Armed Forces and their dependents. To ensure that these protections are provided to eligible applicants, we require you to initial one of the following statements as applicable and sign and date below.

1. ______ I AM a regular or reserve member of the Army, Navy, Marine Corps, Air Force, or Coast Guard, serving on active duty under a call or order that does not specify a period of 30 days or fewer.

2. ______ I AM a dependent of a member of the Armed Forces on active duty because I am the member’s spouse, the member’s child under the age of eighteen years old, or I am an individual for whom the member provided more than one-half of my financial support for 180 days immediately preceding today’s date.

3. ______ I AM NOT a regular or reserve member of the Army, Navy, Marine Corps, Air Force, or Coast Guard, serving on active duty under a call or order that does not specify a period of 30 days or fewer (or a dependent of such a member)

 

Personal References
Name
1.		 Address
 City, State, Zip
 Phone #
 Relationship
2.
3.

Read Statement Before Signing:
I certify the information supplied by me on this form is true and correct.  I authorize verification of the truthfulness of all information contained herein, including contact with any person or firm listed above, and fully release all parties from liability for any damage that may result.  Any false statement made above shall be sufficient basis for rejection.  I have read and understand the above statement.

 

Signature_______________________________________ Date________________