Apply for a Loan

It's Safe, Secure, and Easy.

This form uses 256 bit SSL encryption, ensuring that no one else will see your personal information while it is in transit. Please view our Privacy Policy for more information.

Please select the branch location you wish to work with to complete the new account process: (required)

Please select the branch location you wish to work with to complete the loan process: (required)

Type of Credit Requested:

Secured Unsecured

Individual Credit Joint Credit

Amount Requested: (required)
Term of Loan (in months): (required)
Payment Date Desired:
Proceeds of Loan to Be Used For: (required)
Referred By:

Section B - Joint Applicant or Other Party Information

Complete only if for joint credit, for individual credit relying on income or assets from other sources, or applicant is married and resides in a community property state.

Personal Information:Name (Co-Applicant) ( Last, First, M.I. )
Social Security Number
Date of Birth
Home Phone
E-Mail
Driver's License Number
Relationship to Applicant (if any)

Current Address:Home Address (Co-Applicant) (Not a P.O. Box)
City
State
Zip
Years At Home Address

Dependent Information:Number of Dependents (of Co-Applicant)
Age of Dependents

Employment Information:

Current Employer

Employer's Name
Employer Phone
Employer Address
City
State
Zip
Your Position
Years at Company
Gross Salary Per Month
Net Salary Per Month

Previous Employer

Employer's Name
Employer Phone
Employer Address
City
State
Zip
Years at Previous Company

Other Income Sources

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

Alimony, child support, seperate maintenance income received under:

Court Order
Written
Oral Understanding
None

Sources of Other Income for Co-Applicant
Amount Per Month

Is any income listed in this Section likely to be reduced before the credit request is paid off?

No Yes

Have you previously received credit from us?

No Yes

Section C - Marital Status

Complete only if: for joint or secured credit, or applicant resides in a community property state, or is relying on property located in such a state as a basis for repayment of the credit requested.

Applicant Marital Status:

Married
Seperated
Unmarried
Not Applicable

Co-Applicant Marital Status:

Married
Seperated
Unmarried
Not Applicable

Section E - Secured Credit

Complete this section only if credit is to be secured. Briefly describe the property to be given as security.

Property Description
Co-Owner Name
Co-Owner City
Co-Owner State
Co-Owner Zip
If the security is real estate, give the full name of your spouse (if any)

Credit Consent:

By checking the boxes below, you and any listed co-borrowers give your consent to the lender, its agents, and investors to obtain and review your credit report(s).

Yes

CONSUMER CREDIT DISCLOSURE: An insurance product or annuity may be offered to you. If you purchase an insurance product or an annuity: (1) The insurance product or annuity is not a deposit or other obligation of, or guaranteed by, this institution or our affiliate(s); (2) With exception of Federal Flood Insurance or Federal Crop Insurance, the insurance product or annuity is not insured by the Federal Deposit Insurance Corporation or any other agency of the United States, this institution, or our affiliate(s); and (3) In the case of an insurance product or annuity that involves an investment risk, there is investment risk associated with the insurance product, including the possible loss of value. If an insurance product or annuity is offered we cannot condition an extension of credit on either of the following: (1) Your purchase of an insurance product or annuity from us or any of our affiliates; or, (2) Your agreement not to obtain, or a prohibition on you from obtaining, an insurance product or annuity from an unaffiliated entity.

Security Code

Please enter the letters and numbers from the image above.

By clicking Submit below, if this is an application for joint credit, Borrower and Co-Borrower each agree that they intend to apply for joint credit.

By clicking Submit below, I certify that everything I have stated in this application is correct. The First National Bank of Dieterich may keep this application whether or not it is approved. By submitting this application I authorize The First National Bank of Dieterich to check my credit and employment history and to answer questions others may ask The First National Bank of Dieterich about my credit record with The First National Bank of Dieterich. I understand that I must update credit information at The First National Bank of Dieterich' request if my financial condition changes.

This document is being secured using SSL encryption provided by your browser. Your information will be encrypted when using this form while in transit between your browser and The First National Bank of Dieterich.