Loan Application

Loan Information

• Application Type *

  Individual Joint
• Amount Requested *
• Number of Months *
• Loan Purpose *
• Collateral offered
  If Auto, specify Year/Make/Model

Applicant Information

• Name *
• Social Security Number *
• Date of Birth *
• Street Address *
• City *
• State *
  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
• Zip *
• Time at Current Address *
• Email *
• Phone *
• Employer's Name *
• Position/Title *
• Phone *
• Address *
• Length of time with Current Employer *
• Gross Monthly Income *
• Rent/Mortgage Payment *
• Home Information *
  Rent Own
• Name & Phone of friend/relative not living with you *

Note: Alimony, Child Support or Separate Maintenance Income(s) do not have to be revealed unless you wish to have them considered in loan qualification.

Federal Credit Application Insurance Disclosure

I have applied for an extension of credit with you. You are soliciting, offering, or selling me an insurance product or annuity in connection with this extension of credit. Federal law prohibits you from conditioning the extension of credit on either:

1. My purchase of an insurance product or annuity from you or from any of your affiliates; or
2. My agreement not to obtain, or a prohibition on me from obtaining, an insurance product or annuity from an unaffiliated entity.

By signing, I acknowledge that I have received a copy of this form on today's date. Unless this disclosure is provided electronically or I have applied for credit by mail, I also acknowledge that you have provided this disclosure to me orally.

• Applicant Signature *
• Joint Applicant Signature *

Agreement/Signature

I certify that all information provided by me is true, correct, and complete. I authorize Fowler State Bank to make whatever inquiries about me they deem necessary and appropriate for the purpose of evaluating my credit application, including credit reports and contacting my employer. I also authorize Fowler State Bank to provide credit information about its credit experience with me to other creditors and credit reporting agencies.

• Applicant Signature *
• Joint Applicant Signature *
• Bank Representative