Appalachian Community Bank

* = Required Field

Note: All Applicable Sections Should Be Filled Out Completely. If Not, Processing Of Your Application May Be Delayed.

Is this an individual or joint loan?

Individual Credit Line - relying solely on my income		Joint Credit Line
Individual Credit Line - relying on my income as well as income from other sources
Type of Loan:	Personal Home Mortgage Home Equity

Primary Borrower's Information

Last Name*

First*

Middle*

Social Security Number*

Birthdate (mm/dd/yyyy)*	Number of Dependents*	Home Phone*	Email Address*

Present Address
Street*	City*	State*	ZIP*
Residential Status Rent	Own	Other
Mortgage Holder / Landlord*	Monthly Payment*
Former Address (If at present address less than 2 years)
Street*	City*	State*	ZIP*
Current Employer
Employer*	Job Title*	State*	ZIP*
Street*	City*
Work Phone*
Former Employer
Employer*	Job Title*	State*	ZIP*
Street*	City*
Work Phone*	E-Mail*
Co-Borrower's Information (joint applicant or cosigner only)
Last Name	First	Middle	Social Security Number
Birthdate (mm/dd/yyyy)	Number of Dependents	Home Phone
Present Address
Street	City	State	ZIP
Residential Status Rent	Own	Other
Mortgage Holder / Landlord	Monthly Payment
Former Address (If at present address less than 2 years)
Street	City	State	ZIP
Current Employer
Employer	Job Title
Street	City	State	ZIP
Work Phone
Former Employer (If at present job less than 2 years)
Employer	Job Title
Street	City	State	ZIP
Work Phone
Monthly Income Note: Alimony, child support, or separate maintenance income need not be revealed if the Borrower or Co-Borrower does not choose to have it considered for repaying this loan.
	Borrower	Co-Borrower
Base Employ Income:	*
Overtime / Bonus:	*
Dividends / Interest:	*
Rental Income:	*
Other:	*
Total:	*
Property and Loan Info
Amount requested: $ *	Collateral: *
Do you want Credit Life and Disability Insurance?	Yes No
If yes, coverage should be for	Borrower Co-Borrower
Purpose of Loan: Purchase Refinance Construction Other:
Assets and Liabilities	Please fill out all that apply.
Checking Account Information:
Name of Bank
Account Number
Account Value
Savings Account Information
Name of Bank
Account Number
Account Value

Do you have any additional assets (Other Real Estate, Certificate of Deposit, Money Market Accounts, Cash Value Life Insurance) Yes No If yes, please indicate asset value
Asset Description

Other Loans / Credit Cards:

Company Name 1:
Account Number:
Balance:
Monthly Payment:
Company Name 2:
Account Number:
Balance:
Monthly Payment:
Company Name 3:
Account Number:
Balance:
Monthly Payment:
Company Name 4:
Account Number:
Balance:
Monthly Payment:
Other Loan Payments:
Debt	Monthly Payment	Description

Other Questions
(Check box for 'yes' or leave blank for 'no')

Borrower	Co-Borrower
Yes No	Yes No	Are you a guarantor or co-maker of any leases, contracts, or debts?
Yes No	Yes No	Are there any suits or judgments pending against you?* Amount:
Yes No	Yes No	Have you declared bankrupt in the last 10 years?*

Please explain if you checked yes to any of the above questions:

By sending this electronic application, I certify that everything stated within it is correct. You may keep this application whether or not it is approved. By sending I authorize you to check my credit and employment history and to answer questions others may ask you about my credit record with you. I understand that I must update this credit information at your request and if my financial condition changes.

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