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PRINT CREDIT APPLICATION RESET
TYPE OF CREDIT REQUESTED FOR CREDITOR USE
IMPORTANT: Check (j) the appropriate boxes below and complete the applicable sections. DATE CLASS NO.
0 SECURED 0 INDIVIDUALCREDIT. relyingsolely on my incomeor assets ACCOUNT NO.

0 UNSECURED 0 INDIVIDUAL CREDIT. relying on my income or assets as well as income or assets from other sources
APPROVED 0 BY

0 JOINT CREDIT DECLINED 0 BY

AMOUNT REQUESTED FOR HOW LONG PAYMENT DATE DESIRED WANT TO REPAY PROCEEDS OF LOAN TO BE USED FOR:
0 MONTHLY
$
.. '- 0 ... ....
III SECTION A., -INDIVIDUAL APPLICANT INFORMATION
_.. '-""- .0.. .-. .-
NAME (Last, First, Middle)

BIRTHDA TE

I TELEPHONE
NO. I DRIVER'S LICENSE NO. I SOCIAL SECURITY NO. I NO. D'PENDENTS rOES OF DEPEND'"
ADDRESS (Street, City, State & Zip) COUNTY 0 HOW LONG
.. Do you own
or 0 rent?
COUNTY
PREVIOUS ADDRESS (Street, City, State & Zip) (Complete if less than 3 years at present address) Did you 0 own HOW LONG
or 0 rent?
EMPLOYER (Company Name & Address) HOW LONG

BUSINESS PHONE Ext. SALARY PER MONTH

I POSITIONORTITLE I GROSS: $ NET: $

PREVIOUS EMPLOYER (Company Name & Address) HOW LONG

NAME & ADDRESS OF NEAREST RELATIVE NOT LIVING WITH YOU RELATIONSHIP TELEPHONE NO. (Include Area Code)

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: 0 Court Order 0 Written Agreement 0 Oral Understanding
SOURCES OF OTHER INCOME

I ;MOUNTPERMONTH
Is any income listed in this Section likely to be reduced before the credit request is paid off?
0 No 0 Yes (Explain) 0 No 0 Yes - received
When?
- II
I Have you previously
. cO
credit from us?
SECTION B - JOINT APPLICANT OR OTHER PARTY INFORMATION
Complete onlv if: for joint2redit, for individual ce<;l!t;.yiQ.2e or assets fro,(ll :!!!1er.ources, or applicant is,marrie;d and resids in a commun!.ty property_stte.
NAME (Last, First, Middle)

BIRTHDATE

I TELEPHONE
NO. I DRIVER'S LICENSE NO. I SOCIAL SECURITY NO. I NO. DEPENDENTS I AGES OF DEPENDENTS
RELATIONSHIP TO APPLICANT (If Any) HOW LONG

I PRESENT ADDRESS (Street, City, State & Zip)

EMPLOYER (Company Name & Address) HOW LONG

BUSINESS PHONE Ext. SALARY PER MONTH

I POSITIONORTITLE I GROSS: $ NET: $

PREVIOUS EMPLOYER (Company Name & Address) HOW LONG

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: 0 Court Order 0 Written Agreement 0 Oral Understanding
SOURCES OF OTHER INCOME

I :MOUNTPERMONTH
Is any income listed in this Section likely to be reduced before the credit requested is paid off?
ONo 0 Yes (Explain) 0
HasNo
Joint 0 Yes- When?
- ,. .-- I
-., Applicant or Other Party ever received credit
.. from us?
SECTION C - MARITAL STATUS
Complete only if: for joint or secured credit,"Orapplicant resides in a community property state or is relying
- ;;.,
_on..property located in such a stte as a bai. for repayment of th credit requsted.
APPLICANT 0 Married 0 Separated 0 Unmarried (including single, divorced, and widowed)
OIHE:RPARTY 0 Married - 0 Separated 0 Unmarried (inclyding single, divorced, and.widowed)

~ @ 1986 Bankers Systems, Inc., SI. Cloud, MN Form UCA 10/23/2000 (page 1 of 2)
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MONTHLY
PAYMENTS

~[Ci~~'J"I:I~" I certify that everything I have stated in this application and on any attachments is correct. You may keep this application whether or not it is approved. By signing
below I authorize you to check my credit and employment history and to answer questions others may ask you about my credit record with you. I understand that I must update credit
information at your request if my financial condition changes.

Applicant's Signature Date Other Signature (Where Applicable) Date

~ @ 1986 Bankers Systems, Inc., St. Cloud, MN Form UCA 10/23/2000 (page 2 of 2)