Consumer Loan Application

Phone: (785)295-2100 Fax: (785)290-0460

Purpose:

Vehicle Information

Year:

Make:

Model:

Miles:

Vehicle Identification Number:

Amount Requested:

Insurance Company:

Insurance Agent's Name:

Insurance Agent's Phone (000)000-0000: Insurance Agent's Phone: Area Code ( ) Insurance Agent's Phone: Prefix - Insurance Agent's Phone: Suffix

Disbursement of Funds to:

We intend to apply for joint credit:

(applicant initials) (co-applicant initials)

Applicant

*First Name:

*Last Name:

*DOB(MM/DD/YYYY): DOB Month (MM) / DOB Date (DD) / DOB Year (YY)

*SSN (000-00-0000): First 3 digits of SSN - Middle 2 digits of SSN - Last 4 digits of SSN

*Address:

*City: *ST: *Zip:

*How long at this address?

*Previous Address:

*City: *ST: *Zip:

How long at this address?

*Home Phone (000)000-000: Home Phone: Area Code ( ) Home Phone: Prefix - Home Phone: Suffix

Cell Phone (000)000-0000: Cell Phone: Area Code ( ) Cell Phone: Prefix - Cell Phone: Suffix

*Email Address:

*Employer:

*Occupation:

*How long at this employer?

Work Phone (000)000-0000: Work Phone: Area Code ( ) Work Phone: Prefix - Work Phone: Suffix

*Previous Employer:

*How long at this employer?

Work Phone (000)000-0000: Previous Employer Work Phone: Area Code ( ) Previous Employer Work Phone: Prefix - Previous Employer Work Phone: Suffix

Joint Applicant

*First Name:

*M:

*Last Name:

*DOB(MM/DD/YYYY): Joint DOB Month (MM) / Joint DOB Date (DD) / Joint DOB Year (YY)

*SSN (000-00-0000): Joint SSN: First 3 digits - Joint SSN: Middle 2 digits - Joint SSN: Last 4 digits

*Address:

*City: *ST: *Zip:

*How long at this address?:

*Previous Address:

*City: *ST: *Zip:

How long at this address?

*Relationship to Applicant:

*Home Phone (000)000-0000: Joint Home Phone: Area Code ( ) Joint Home Phone: Prefix - Joint Home Phone: Suffix

Cell Phone (000)000-0000: Joint Cell Phone: Area Code ( ) Joint Cell Phone: Prefix - Joint Cell Phone: Suffix

*Email Address:

*Employer:

*Occupation:

*How long at this employer?

Work Phone (000)000-0000: Joint Work Phone: Area Code ( ) Joint Work Phone: Prefix - Joint Work Phone: Suffix

*Previous Employer:

*Occupation:

*How long at this employer?

Work Phone (000)000-0000: Joint Previous Employer Work Phone: Area Code ( ) Joint Previous Employer Work Phone: Prefix - Joint Previous Employer Work Phone: Suffix

Income and Debts

Applicant

Applicant Gross monthly Salary:

Other Monthly Income:

Source Other Income:

Mortgage/Rent Payment:

Auto Payment:

++Child Support/Alimony, etc.:

Other Debt:

Joint Applicant

Gross Monthly Salary:

Other Monthly Income:

Source Other Income:

Mortgage/Rent Payment:

Auto Payment:

++Child Support/Alimony, etc.:

Other Debt:

++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.

Personal References

References/Family or Friends not living in the same household

Name:

Phone(000)000-0000: Reference 1 Phone: Area Code ( ) Reference 1 Phone: Prefix - Reference 1 Phone: Suffix

Relationship:

Address:

City: ST: Zip:

Name:

Phone (000)000-0000: Reference 2 Phone: Area Code ( ) Reference 2 Phone: Prefix - Reference 2 Phone: Suffix

Relationship:

Address:

City: ST: Zip:

MARITAL STATUS (Do not complete if this is an application for individual unsecured credit.)

Applicant

Married Separated Unmarried (including single, divorced, and widowed)

Other Party:

Married Separated Unmarried (including single, divorced, and widowed)