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Note: A consumer report may be requested in connection with this application. Upon your request, we will inform you whether or not a report was requested and notify you of the name and address of the consumer reporting agency that furnished the information. We may request subsequent reports without additional notice.

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If you are applying for individual credit in your own name and are relying on your own income or assets and not the income or assets of another person as the basis for repayment of the credit requested, complete the Borrower section omitting the Co-Borrower section.
If this is an application for joint credit with another person, complete both the Borrower and Co-Borrower section.
If you are applying for individual credit, but are relying on income from alimony, child support, or separate maintenance or on the income or assets of another person as the basis for repayment of the credit requested, complete all sections to the extent possible, providing information about the person on whose alimony, child support, or maintenance payments or income or assets you are relying.

General Information
Amount Requested (minimum $2000)
Term Requested (years)
Type of credit applied for
Make
Model
Mileage

 

Borrower Information
Borrower - Complete Column # 1 Co-Borrower - Complete Column # 2
Social Security Number
Social Security Number
Date of Birth
Date of Birth
First Name
First Name
Middle Initial
Middle Initial
Last Name
Last Name
Current Address
Current Address
Years at Current Address
Years at Current Address
City, State, Zip
City, State, Zip
County
County
Previous Address (if less than 3 years)
Previous Address (if less than 3 years)
City, State, Zip
City, State, Zip
County
County
Number of Dependents
Number of Dependents
Age of Dependents (separate by ;)
Age of Dependents (separate by ;)
Daytime Phone Number
Daytime Phone Number
Evening Phone Number
Evening Phone Number
Relationship to Co-Applicant (if any)
 
Marital Status
Married Separated
Unmarried (single, divorced, widowed)
Marital Status
Married Separated
Unmarried (single, divorced, widowed)
Email Address
Email Address

 

Employment Information
Borrower - Complete Column # 1 Co-Borrower - Complete Column # 2
Self-Employed Yes No Self-Employed Yes No
Place of Employment
Place of Employment
Employer's Address
Employer's Address
City, State, Zip
City, State, Zip
Occupation
Occupation
Length of time with this Employer (in years)
Length of time with this Employer (in years)
Annual Gross Income
Annual Gross Income
Previous Employer (if less than 3 years)
Previous Employer (if less than 3 years)
Previous Employer's Address
Previous Employer's Address
City, State, Zip
City, State, Zip
Note: Alimony, child support, or separate maintenance income need not be revealed if you do not wish it to be considered as a basis for repaying this obligation.
Other Sources of Income Other Sources of Income
Amount
Amount
Source
Source

 

Nearest Relative Not Living With You
Borrower - Complete Column # 1 Borrower - Complete Column # 2
Nearest Relative's Name
Nearest Relative's Name
Address
Address
City, State, Zip
City, State, Zip
Relative's Phone Number
Relative's Phone Number

 

Assets
List all assets owned, including real estate, automobiles, marketable securities, cash value of insurance policies, etc. Be sure to indicate name(s) of owner(s).
Description Value Subject To Debt Name(s) Of Owner(s)

 

Deposit Account Information
Borrower - Complete Column # 1 Borrower - Complete Column # 2
Checking Savings Checking Savings
Bank
Bank
Bank
Bank
Branch
Branch
Branch
Branch

 

Credit Information
Borrower - Complete Column # 1 Borrower - Complete Column # 2
Housing Status
Own Rent
Living with a relative
Other
Housing Status
Own Rent
Living with a relative
Other
Mortgage Holder
Mortgage Holder
Monthly Mortgage Payment/Rent
Monthly Mortgage Payment/Rent
Other Loans/Credit Cards Other Loans/Credit Cards
Company 1
Company 1
Balance
Balance
Minimum Monthly Payment
Minimum Monthly Payment
Company 2
Company 2
Balance
Balance
Minimum Monthly Payment
Minimum Monthly Payment
Company 3
Company 3
Balance
Balance
Minimum Monthly Payment
Minimum Monthly Payment
Company 4
Company 4
Balance
Balance
Minimum Monthly Payment
Minimum Monthly Payment
Company 5
Company 5
Balance
Balance
Minimum Monthly Payment
Minimum Monthly Payment

 

Other Information
Are you a co-maker, endorser, or guarantor on any loan or contract?
If yes, for whom? To whom?
Are there any unsatisfied judgements against you?
If yes, amount?
Have you been declared bankrupt in the last 7 years?
If yes, where?
Other Obligations: List other obligations including liability to pay alimony, child support, or separate maintenance.
 
I/We authorize you to make such inquiries regarding the information furnished herein as may be required in connection with the application or in the course of review or collection of any credit extended in reliance on the application. I/We authorize you to release information about my/our credit experience with Pioneer Bank. I/We authorize and instruct any person or consumer reporting agency to complete and furnish to the lender any information it may have or obtain in response to such credit inquiries and agree that same shall remain your property whether or not credit is extended. All information set forth in this application is disclosed to be a true representation of facts for the purpose of obtaining the credit and any willful misrepresentation on this application could result in criminal action. I/We understand that other financial information may be requested in connection with this loan application.
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