Centier

Consumer Loan Application

Consumer Loans

Select the appropriate box to indicate individual or joint credit.

- Check here if you are applying for individual credit and relying on your own income or assets and not the income or assets of another person as the basis for repayment of the credit requested.
- Check here if you are applying for joint credit with another person and provide information about the joint applicant.

Loan Information

Required information*

Amount Requested*
Type of Loan*

Loan Purpose - Check all that apply

What is the reason for your Centier Savings / CD loan request?*

For Centier Savings / CD loan, list your savings or CD account number

If the purpose is to payoff debts with the proceeds of this loan, list creditor balance:

Creditor	Balance	Creditor	Balance

Name of Dealer or Seller

If vehicle is financed, Name of Company

Short Description of the Vehicle

Year

Make

Model

Mileage

Options

Please describe the loan purpose.*
Term in Years*
Applicant Type

Applicant Information

Last Name*
First Name*
Middle Initial
Suffix
Birth Date*
MM/DD/YYYY
Social Security Number*
XXX-XX-XXXX

Address*
City*
State*
Zip*

How long at Current Residence?
Years*
Months*

Home Phone*
(XXX) XXX-XXXX
Cell Phone
(XXX) XXX-XXXX
Email Address

Current Employer
or Source of Income*
City
State

How Long with Current Employer?
Years
Months

Business Phone
(XXX) XXX-XXXX
Position
Gross Salary Per Month
Social Security / Disability
Pension / Retirement

Sources of Other Income: Alimony, child support or separate maintenance need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.
Other Income Source
Amount Per Month

Do you pay child support?*
Yes
No
If yes, monthly amount

Checking Account:
Bank Name:
Savings Account:
Bank Name:

Joint Applicant or Other Party Information

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

Last Name*
First Name*
Middle Initial
Suffix
Birth Date*
MM/DD/YYYY
Social Security Number*
XXX-XX-XXXX

Address*
City*
State*
Zip*

How long at Current Residence?
Years
Months

Home Phone*
(XXX) XXX-XXXX
Cell Phone
(XXX) XXX-XXXX
Email Address

Current Employer
or Source of Income
City
State

How Long with Current Employer?
Years
Months

Business Phone
(XXX) XXX-XXXX
Position
Gross Salary Per Month
Social Security / Disability
Pension / Retirement

Sources of Other Income: Alimony, child support or separate maintenance need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.
Other Income Source
Amount Per Month

Do you pay child support?
Yes
No
If yes, monthly amount

Checking Account:
Bank Name:
Savings Account:
Bank Name:

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, select your marital status from the drop down menu.*
Other Party, select your marital status from the drop down menu.*

Notice of negative information:
We may report information about your account to credit bureaus. Late payments, missed payments or other defaults on your account may be reflected in your credit report.
SIGNATURES:
I certify that everything I have stated in this application and on any attachments is correct. You may keep this application whether or not it is approved. By submitting below I authorize you to optain my credit bureau and employment history and to answer permissible questions, under the Fair Credit Reporting Act, others may ask you about my credit record with you. I understand that I must update credit information at your request if my financial condition changes.