CCB Loan Application

Do Something Great with a Loan from CCB!

Just about everyone will borrow at some point in their lives. The good news is when you borrow from a friendly, local bank like Citizens Community Bank, you get the personal attention you need to get the right loan for your budget and situation. You also get all the conveniences that larger banks offer. It really is the best of both worlds.

Loan Info

Secured Loan?* Secured Unsecured

Amount Requested:*

Loan Purpose:*

Your Contact Info

Full Name:*

Birth Date*

E-Mail Address:

Primary Phone:*

Secondary Phone:

Your Address Info

Street Address:*

City:*

State:*

ZIP Code:*

How long have you lived at your current residence?*

Previous Address:

How long did you lived at your previous residence?

Your Personal Info

Social Security Number:*

Total Number of Dependents:*

Driver's License Number:*

Driver's License Issue Date*

Driver's License Expiration Date*

Your Personal Info

Do you have a Bank Account?* Yes No

What type of bank account(s) do you have?* Checking Savings

What bank is your account(s) with?*

Nearest relative not living with you:*

Relationship to that relative:

Nearest relative's phone:*

Nearest relative's address:

Your Employer Info

Employer's Name:*

Employer Phone:

Employer Street Address:*

Employer City:*

Employer State:*

Employer ZIP Code:*

Employment Status

Position or Occupation:*

How long have you been employed there?*

Applicant's Monthly Income

Applicant's Gross Monthly Pay*

List Any Other Income

Total Gross Monthly Pay*

Financial Obligations

List all debts and monthly payments below

Creditor* Monthly Payment* Balance Creditor Monthly Payment Balance Creditor Monthly Payment Balance Creditor Monthly Payment Balance Creditor Monthly Payment Balance Creditor Monthly Payment Balance Creditor Monthly Payment Balance

Joint Application?* Yes No

Joint Applicant Address Info

Street Address:*

City:*

State:*

ZIP Code:*

How long has the joint applicant lived at the current residence?*

Previous Address:

How long did you lived at your previous residence?

Joint Applicant Personal Info

Do you have a Bank Account? Yes No

What type of bank account(s) do you have?* Checking Savings

What bank is your account(s) with?*

Joint Applicant Social Security Number:*

Driver's License Number:*

Driver's License Issue Date*

Driver's License Expiration Date*

Joint Applicant Employer Info

Joint Applicant Employer's Name:*

Employer Phone:

Employer Street Address:*

Employer City:*

Employer State:*

Employer ZIP Code:*

Joint Applicant Employment Status

Position or Occupation:*

How long have you been employed there?*

Joint Applicant's Monthly Income

Joint Applicant's Monthly Gross Pay*

List Any Other Income (Explain)

Joint Applicant Total Monthly Income*

Joint Applicant Financial Obligations

List all debts and monthly payments below

Creditor* Monthly Payment* Balance Creditor Monthly Payment Balance Creditor Monthly Payment Balance Creditor Monthly Payment Balance Creditor Monthly Payment Balance Creditor Monthly Payment Balance Creditor Monthly Payment Balance

Other Obligations

Are there any unsatisfied judgements or liens against any party to this application? Yes No

If yes, explain the circumstances

Has there ever been a bankruptcy proceeding filed by any party to this application? Yes No

If yes, explain the circumstances

Is any party to this application a co-maker, endorser or guarantor on any other loan or contract? Yes No

If yes, explain the circumstances

Alimony, child support or separate maintenance income need not be revealed if you do not wish to have it considered as basis for repaying this obligation.

Alimony, child support or separate maintenance income received under: Court Order Written Agreement Oral Understanding

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:

My purchase of an insurance product or annuity from you or any affiliates: or
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 or if 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.

Everything that I have stated in this application is correct to the best of my knowledge. I understand that you will retain this application whether or not it is approved. You are authorized to check my credit and employment history and to answer questions about credit experience with me.

Thank you for completing your Citizens Community Bank loan application.

We will process your information and contact you very soon.

Have a great day!

Do Something Great with a Loan from CCB!

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