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| Internet Loan Application | |||||||||
| Privacy Policy: Our privacy policy protects the privacy of your personally- | |||||||||
| identifying information that you provide us online. | |||||||||
| Applicants must reside in the State of Kansas | |||||||||
| Important Information about Procedures for Opening a New Account | |||||||||
| Identification Procedures Requirements: To help the government fight the funding | |||||||||
| of terrorism and money laundering activites, Federal law requires all financial | |||||||||
| institutions to obtain, verify, and record information that identifies each person who | |||||||||
| opens an account. | |||||||||
| What this means for you: When you open an account, we will ask for your name, | |||||||||
| address, date of birth, and other information that will allow us to identify you. We | |||||||||
| may also ask to see your driver's license or other identifying documents. | |||||||||
| Security Notice: You should ONLY fill out this deposit application on-line if you | |||||||||
| are using a browser, such as Netscape or Explorer, with the latest security | |||||||||
| enhancements. If you don't have the latest version, download a copy now. This form | |||||||||
| is NOT cached (saved in your computer's memory) when you Quit your browser. | |||||||||
| Instructions: | |||||||||
| 1. Print this deposit application and gather the information you'll need. | |||||||||
| 2. Fill out the application and fax it to (785) 628-2476 | |||||||||
| 3. Upon approval of your application, the account documentation will be sent via-mail or | |||||||||
| if you choose, stop by one of our convenient locations to complete the forms. | |||||||||
| 4. For your security, funds will not be released until the proper signed documentation | |||||||||
| is received by First National Bank. | |||||||||
| A Valid Social Security Number is required to apply. Please review and gather the | |||||||||
| information you will need before completing this form. | |||||||||
| Loan Request | |||||||||
| Type of Application: | |||||||||
| □ Individual Account □ Joint Applicant | |||||||||
| Type of Loan | |||||||||
| □ Auto Loan | □ Personal Secured | ||||||||
| □ Home Equity | □ Personal Unsecured | ||||||||
| Amount Requested | If Personal Loan, indicate purpose | ||||||||
| Tell Us About Yourself | |||||||||
| First Name | Middle Initial | Last Name | |||||||
| Date of Birth | Social Security No. | No. of Dependents | |||||||
| Driver's License No. | Driver's License State | Your E-Mail Address | |||||||
| Home Phone | Best Time To Call | Work Phone | |||||||
| Are there any unsatisfied Judgements against you? □ yes □ no | |||||||||
| Have you been declared bankrupt in the last 7 years? □ yes □ no | |||||||||
| Joint Applicant | |||||||||
| First Name | Middle Initial | Last Name | |||||||
| Date of Birth | Social Security No. | No. of Dependents | |||||||
| Driver's License No. | Driver's License State | Your E-Mail Address | |||||||
| Home Phone | Best Time To Call | Work Phone | |||||||
| Are there any unsatisfied Judgements against you? □ yes □ no | |||||||||
| Have you been declared bankrupt in the last 7 years? □ yes □ no | |||||||||
| Your Residence | |||||||||
| Present Street Address | City | State | Zip | ||||||
| Years at Present Address | Your Monthly Rent or Mortgage Payment | ||||||||
| Years at Previous Address | Your Previous Address | ||||||||
| Home Information | |||||||||
| Collateral Property Address (If different from Above) | Date Purchased | ||||||||
| Current Mortgage Holder | Mortgage Holder Phone | ||||||||
| Purchase Price | Market Value | Mortgage Balance | |||||||
| Your Employment | |||||||||
| □ Employed □ Self-Employed □ Retired □ Unemployed □ Student | |||||||||
| Your Present Employer | Phone | ||||||||
| Street Address | City | State | Zip | ||||||
| Years at current employer | Your Position | Gross Monthly Income | |||||||
| You do not have to list alimony, child support or separate maintenance income unless you want us | |||||||||
| to consider it for the purposes of granting and repayment of this credit request. | |||||||||
| Other Monthly Income | Source of Other Income | ||||||||
| Previous Employer (if less than 3 years at current employer) | Years at Previous Employer | ||||||||
| Previous Employer Street Address | City | State | Zip | ||||||
| Additional Information | |||||||||
| Your Checking Account Number | Institution Name | ||||||||
| Your Savings Account Number | Institution Name | ||||||||
| Name of Creditor | Approximate Balance | Monthly Payment | Collateral, if any | ||||||
| Total Amount of "Other" Monthly Payments not listed above: | |||||||||
| Assets | Value | Title Held Name | |||||||
| This Section for AUTO LOAN Applicants | |||||||||
| Year of Vehicle | Make | Model | |||||||
| Purchase Price | Down Payment | Finance Amount | |||||||
| Trade-in □ Yes □ No | Purchasing from Dealer □ Yes □ No | ||||||||
| Dealer Name | |||||||||
| This Section for HOME EQUITY LOAN Applicants | |||||||||
| Information for Government Monitoring Purposes | |||||||||
| This section to be completed only for loans subject to reporting under the Home | |||||||||
| Mortgage Disclosure Act (HMDA). | |||||||||
| HMDA loans are loans make for the following purposes: Home Purchase | |||||||||
| (secured), Home Improvement (secured or unsecured), or refinance of a loan | |||||||||
| secured by a 1-4 residential dwelling (regardless of purpose). | |||||||||
| The following information is requested by the Federal government for certain | |||||||||
| types of loans related to a dwelling, in order to monitor the Lender's compliance | |||||||||
| with equal credit opportunity, fair housing and home mortgage disclosure laws. | |||||||||
| You are not required to furnish this information, but are encouraged to do so. | |||||||||
| The law provides that a Lender may discriminate neither on he basis of this | |||||||||
| information, nor on whether you choose to furnish it. | |||||||||
| If you choose to furnish the information, please provide both ethnicity and race. | |||||||||
| For race, you may check more than one designation. If you do not furnish | |||||||||
| ethnicity, race, or sex, under Federal regulations, this Lender is required to note | |||||||||
| the information on the basis of visual observation or surname. | |||||||||
| If you do not wish to furnish the above information, please check the box below. | |||||||||
| (Lender must review the above material to assure that the disclosures satisfy all | |||||||||
| requirements to which the Lender is subject under applicable state law for the | |||||||||
| particular type of loan. | |||||||||
| Applicant | Co-Applicant | ||||||||
| □ I do not wish to furnish this information | □ I do not wish to furnish this information | ||||||||
| Ethnicity: | Ethnicity: | ||||||||
| □ Hispanic or Latino | □ Hispanic or Latino | ||||||||
| □ Not Hispanic or Latino | □ Not Hispanic or Latino | ||||||||
| Race or National Origin: | Race or National Origin: | ||||||||
| □ American Indian, Alaskan Native | □ American Indian, Alaskan Native | ||||||||
| □ Asian | □ Asian | ||||||||
| □ Native Hawaiian or other Pacific Islander | □ Native Hawaiian or other Pacific Islander | ||||||||
| □ White | □ White | ||||||||
| □ Black or African American | □ Black or African American | ||||||||
| Sex: | Sex: | ||||||||
| □ Female | □ Male | □ Female | □ Male | ||||||
| Applicant(s) Statement | |||||||||
| I/We certify that all information contained herein is accurate and complete toe the best of my knowledge. | |||||||||
| I/We authorize First National Bank to obtain a copy of my current credit report as a condition of acceptance | |||||||||
| of this application. | |||||||||
| I/We acknowledge that this application is subject to approval by First National Bank. Should my request be | |||||||||
| approved, I/We agree to give First National Bank written notice immediately upon change of my name, address, | |||||||||
| employment or any other pertinent information contained herein. | |||||||||
| For more information about | |||||||||
| First National Bank products and services | |||||||||
| Call: | Fax: | ||||||||
| 785-628-2400 | 785-628-2476 | ||||||||