Citizens State Bank Loan Application Form

Complete Your Consumer Loan Application

U.S. Federal Law requires financial institutions to obtain, verify, and record information that identifies each person who opens an account. When you open an account, we will ask for your name, address, date of birth, driver’s license, social security number, and other information that will allow us to identify you.
General Loan Information
Purpose of Loan*

AutomobileHome ImprovementRecreational VehicleVacationDebt ConsolidationOther
Desired Loan Amount $*
Collateral*

AutomobileDeposit AccountRecreational VehicleOther
Depending upon the type of loan you are applying for, additional information may be required.
Type of Credit Requested*

Individual Credit - Relying Solely On My IncomeIndividual Income - Relying On My Income As Well As Income From Other SourcesJoint Credit - Relying On My Income and the Income Of Others
Do you currently have a banking relationship with us?*

YesNo
Monthly Payment Obligations
Housing Payment*
Total Other Monthly Payments*
PERSONAL Information
Name*

First NameLast Name
Social Security Number*
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
P.O. Box (If applicable)
CONTACT Information
E-mail*

Confirmation Emailexample@example.com
Work Phone*
Home Phone
Employment Information
Employment Status*

EmployedSelf EmployedUnemployedRetiredOther
Present Employer*
Industry*
Job Title*
Monthly Salary*
Other Monthly Income*
Years at Employer*

< 1 Year1-5 Years6-10 Years10+ YearsOther
Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employment History
Previous Employer*
Industry*
Years at Previous Employer*
Previous Employer
Industry
Years at Previous Employer
Do you need a Co-Applicant?*

YesNo
Co-Applicant

Please fill out this section if you selected "Yes"
Personal Information
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Information
Email*

Confirmation Emailexample@example.com
Work Phone*
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Employment Information
Employment Status*

EmployedSelf EmployedUnemployedRetiredOther
Present Employer*
Industry*
Job Title*
Monthly Salary*
Other Monthly Income*
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.
Source of Other Monthly Income*
Employment History
Previous Employer
Industry
Years at Previous Employer
Previous Employer
Industry
Years at Previous Employer
Are you working with a loan officer?*

YesNo
Loan Officer
Loan Officer Name
Agreement
I Agree: That everything I have stated in this loan inquiry is correct. That the Lender may keep this inquiry information whether or not it is approved. I authorize Lender to check my credit and employment history and to answer questions others may ask Lender about my credit record with Lender. That I must update credit information at Lender’s request if my financial condition changes. I have read and accept the above disclosures.*

YES
Should be Empty:

Complete Your Consumer Loan Application

General Loan Information

Monthly Payment Obligations

PERSONAL Information

CONTACT Information

Employment Information

Employment History

Co-Applicant

Personal Information

Contact Information

Employment Information

Employment History

Loan Officer

Agreement