Type of Credit Requested:
Secured UnsecuredIndividual Credit
- Relying on my income or assets
Individual Credit - Relying on income or assets, from me and others
Joint Credit Amount Requested: Term of Loan: Payment Date Requested: Repay: Monthly Bi-Weekly Purpose of Loan: Account Number: Account Type: Individual Applicant Information Name: Date of Birth: Phone: Social Security Number: Present Address: City: State: Zip: County: How Long: Previous Address: City: State: Zip: County: How Long: Number of Dependents: Dependents Ages: Name of Nearest Relative:
(Not Living with you)Relationship of Relative:
Relative Address: City: State: Zip: Relative Phone: Employer Name: Employer Address: City: State: Zip:
How Long Employed: Position: Phone: Salary per Month: How Often Paid:
Previous Employer Name: Employer Address: City: State: Zip:
How Long Employed: Position: Phone:
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 Income received under:
Court Order Written Agreement
Oral Understanding Sources of Other Income: Amount / Month:
Joint Applicant Information
Complete this section only if applying for Joint Credit or for Individual Credit
relying on income or assets from other sources, or applicant is married and resides in a Community Property state.Name: Date of Birth: Phone: Social Security Number: Present Address: City: State: Zip: County: How Long: Previous Address: City: State: Zip: County: How Long: Number of Dependents: Dependents Ages: Name of Nearest Relative:
(Not Living with you)Relationship of Relative: Relative Address: City: State: Zip: Relative Phone: Employer Name: Employer Address: City:
State: Zip: How Long Employed: Position: Phone:
Salary per Month: How Often Paid:
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 Income received under:
Court Order
Written Agreement Oral Understanding Sources of Other Income: Amount / Month: Marital Status
Complete this section only if applying for Joint Credit or for Individual Credit relying on income or assets from other sources, or applicant is married and resides
in a Community Property state.Applicant Status:
Married
Separated
Unmarried (Includes Single, Divorced and Widowed) Joint Applicant Status:
Married
Separated
Unmarried (Includes Single, Divorced and Widowed) Assets and Liabilities Information Assets  Checking Account #: Balance:
Bank name and Address: Savings Account #: Balance: Bank name and Address: Automobile Make: Year: Value: Stocks and Bonds Description: Value:Other Assets: Value: Other Assets: Value: Other Assets: Value: Other Assets: Value:
Liabilities 
Name of Company: Account Number: Monthly Payment: Unpaid Balance: Name of Company: Account Number: Monthly Payment: Unpaid Balance: Name of Company: Account Number: Monthly Payment: Unpaid Balance: Name of Company: Account Number: Monthly Payment: Unpaid Balance: Name of Company: Account Number: Monthly Payment: Unpaid Balance: Secured Credit
Complete this section only if credit is to be secured. Briefly describe the property to be given as security and indicate if others have an ownership interest.
Property Description:
Name(s) and Address(s) of all Co-Owners of the Property:
If Security is Real Estate give
full name of Spouse (If any): 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 submitting this form I authorize First Community Bank, its
successors, agents and assigns to check my credit and empolyment history and to answer questions others may
ask you about my credit with you. I understand that I must update my credit information at your request if my financial condition changes. |