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Applicant

Date: Time: Source:

Purpose of Loan:

Amount Requested:

Name: (First, Middle, Last)

Address: (Include Apt#)

City, State, Zip

Birth Date: (mm/dd/yy) SS#

Phone No. Nearby Phone # Whose?

Drivers Lic. Number: Drivers Lic. Expiration Date:

(Check One) > Married: Unmarried: Separated: Number of dependent children:

How Long At Present Address? Years in Area: Check One > City Out of City

(Check One) > Renting? Buying? Own Home? Own M.H.? Buying M.H.? Monthly Payment/Rent?

Landlord or Mortgage Holder: Balance on Mortgage:

Address and Phone Nr. of Landlord or Mortgage Holder:

Former Address: How Long There? Native Home:

Bank: Checking Loan Savings CC Checking Acct# Savings Acct #

Auto Description #1: Lienholder:

Auto Description #2: Lienholder:

Spouse

Name: (First, Middle, Last) SS#: Birth Date:

Employer: Location: Phone:

Date Employeed (mm/dd/yy) Take Home Pay:

Previous Employer How Long: Reason for Leaving:

Dollar Amount Requested:

Employment

Employer: Location: Phone:

Employment Date: Job Title Description:

Supervisor or Dept: Work Hours: Pay Day:

Take Home Pay: (Week) (Month) Other Income:

Other Income Source Total Income Per Month: Verified By:

Previous Employment: How Long: Reason for Leaving:

Previous Employment: How Long: Reason for Leaving:

Previous Employment: How Long: Reason for Leaving:

Personal References

List Five (5)

Name: Relationship: Telephone #: Employer
Full Address: City: State: Zip:

Name: Relationship: Telephone #: Employer
Full Address: City: State: Zip:

Name: Relationship: Telephone #: Employer
Full Address: City: State: Zip:

Name: Relationship: Telephone #: Employer
Full Address: City: State: Zip:

Name: Relationship: Telephone #: Employer
Full Address: City: State: Zip:

Name: Relationship: Telephone #: Employer
Full Address: City: State: Zip:

Have you ever filed Bankruptcy? check if yes. Type: Year:

Have you ever had a repossession? check if yes. Type: Year:

If yess to either of the above, give details

Do you have any Judgements, Garnishments, or Legal Proceedings against you? check if yes.

I/We understand that you are relying on the accuracy and completeness of all information given by Me/Us to you in granting this loan or refinancing. I/We have reviewed the foregoing information and do state that it is complete and true. In connection with this application and any loans made pursuant hereon. I/We authorize Colquitt Fin. to receive and exchange credit information.
Please Sign Below before mailing or sending by fax.



Signatures

 

Finance Employee:

Borrower:

Date:
   

Spouse if Joint Applicant

  

Date: