Equal Housing Lender                                                                                Member FDIC

Please fill out, print and fax this Loan Application Form to 620-326-5598 (Bank of Commerce Fax Line).

This application will not be deemed completed until such applicant signs this form with appropriate documentation in person at the Bank of Commerce in Wellington.

Complete all that apply.

Section A -- Information Regarding Applicant

Last Name: First Name: Middle initial:

                                   Date of Birth:--            Phone Number:-- 

Amount Requested:  .00  Payment Date Desired: --  Proceeds used for:

U.S. Person: Y   N Drivers License No.:   State Issued:          Date of Expiration:--20

Social Security Number or Tax I.D. Number: -- Military ID or Passport Number

Physical Residential Address:   How long at present address?

Previous Address: How long at previous address? email address:

Present Employer: Occupation: Position or Title:  

Length of Employment: Previous Employer: How long with previous employer? 

Your present GROSS salary or commission: Per month/week: Net Salary or Commissions:

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.

Other Income: Per month/week:  

Sources of other income:

Have you ever received credit from the Bank of Commerce? Yes No  

If Yes, when?

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

Explain:

Checking Account Number:

Financial Institution: Address: City: State

Savings Account Number: 

Financial Institution: Address: City: State

Name and address of nearest relative not living with you

Relationship:Phone Number:

Section B - Information Regarding Joint Applicant or other party.

Last Name:First Name:Date of Birth:Phone Number: 

Amount Requested:    Payment Date Desired:   

Proceeds used for:  

U.S. Person: Y or N Drivers License No.: State Issued:  

Date of Expiration:  

Social Security Number or Tax I.D. Number: 

Physical Residential Address:   How long at present address?

Previous Address:   How long at previous address?   email address: 

Present Employer:   Occupation: Position or Title:   

Length of Employment:

Previous Employer: How long with previous employer?

Your present GROSS salary or commission: Per month/week:  

Net Salary or Commissions:

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.

Other Income: Per month/week: Sources of other income:

Have you ever received credit from the Bank of Commerce? Yes No  

If Yes, when?

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

Explain:

Checking Account Number:

Where:

Savings Account Number:

Where:

Name and address of nearest relative not living with you

 Relationship: Phone Number:

Section C - Marital Status (Do not complete if this is an Application for individual unsecured credit.)

Applicant:    MarriedSeparated Unmarried (Including single, divorced or widowed)

Other party: MarriedSeparated Unmarried (Including single, divorced or widowed)

Section D - Asset and Debt Information

Assets Owned:                                              

Cash on hand                                              Value 

Automobiles    Value Subject to Debt YesNo       Owners

Automobiles    Value Subject to Debt YesNo       Owners

Automobiles    Value Subject to Debt YesNo       Owners

Life Insurance:                                   Cash  Value Subject to Debt YesNo   

Owners or beneficiaries:

 Real Estate, Location, Date Acquired:

 Real Estate:                   Value Subject to Debt YesNo          Owners

Marketable securities:     Value Subject to Debt YesNo          Owners

Other:  Value Subject to Debt YesNo          Owners

Other:  Value Subject to Debt YesNo          Owners

Other: Value Subject to Debt YesNo          Owners

Total All Assets           Value

Outstanding Debts

Total Debts                                                                                                                             

Credit References:                                                                                                                                                                       

My auto agent is:

Are you the co-maker, endorser, or guarantor on any loan or contract?No Yes

For Whom?

To Whom?

Are there any unsatisfied judgments against you? No Yes-Amount?   To Whom?

Have you been declared bankrupt in the last ten years? NoYes-Where?Year?

Other obligations (child support, alimony, etc.)

Section E - Secured Credit (Complete only if credit is to be secured.)  Briefly describe the property to be given as security:

Description of property:

Name and Address of all co-owners of property:

If the security is real estate, give the full name of your spouse (if any):

Credit Disclosures:  An insurance product or annuity maybe 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, or guaranteed by, this institution or our affiliate(s); (2) With the 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); (3) In the case of an insurance product or annuity that involves 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 form us or any of our affiliate(s; or, (2) Your agreement not to obtain, or a prohibition on you from obtaining, an insurance product or annuity from an unaffiliated entity.

This application will not be deemed completed until such applicant signs this form with appropriate documentation in person at the Bank of Commerce in Wellington.

Signatures:

Everything I have stated in this Application is correct to the best of my knowledge. I understand that you will retain this Application whether or not it is approved.  You are authorized to check my credit and employment history and answer questions about your credit experience with me.

Applicants signature:  Date:

Unless I have purchased the insurance products by mail or if the Credit Disclosures are provided electronically, by signing below, I acknowledge that I have received the Credit Disclosures orally at the time I have applied for credit and fully understand the disclosures noted above.  I am also being provided with a copy of these disclosures and I acknowledge receipt by my signature:

Other Signature (Where applicable):   Date: