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Consumer Application

APPLICATION INFORMATION
Application for:	Amount Requested:
Purpose of Loan:

Borrower (referred to as B below)
Name		D.O.B. (MM/DD/YYYY)	School Yrs Attended:
Present Address (include City)	State Zip	Number of Years at this address Years: Own Rent
Former Address (include City)	State Zip (if less than 2 years at present address)	Number of Years at this address Years: Own Rent
Driver's License Number		Phone # (000-000-0000)
Social Security Number (XXX-XX-XXXX)		Business Phone (000-000-0000)
Marital Status Married Unmarried (including single, divorced, widowed) Separated		Dependents other than listed by Co-Borrower
		No.	Ages
Name of Employer Address State Zip		Years employed in this line of work or profession? yrs. Years on this job Self-employed
Position/Title		Type of Business

Co-Borrower (referred to as C below)
Name		D.O.B. (MM/DD/YY)	School Yrs Attended:
Present Address (include City)	State Zip	Number of Years at this address Years: Own Rent
Former Address (include City)	State Zip (if less than 2 years at present address)	Number of Years at this address Years: Own Rent
Driver's License Number		Phone # (000-000-0000)
Social Security Number		Business Phone (000-000-0000)
Marital Status Married Unmarried (including single, divorced, widowed) Separated		Dependents other than listed by Co-Borrower
		No.	Ages
Name of Employer Address State Zip		Years employed in this line of work or profession? yrs. Years on this job Self-employed
Position/Title		Type of Business

GROSS MONTHLY INCOME				MONTHLY HOUSING EXPENSE
Item	Borrower	Co-Borrower	Total	Item	Total
Base Empl. Income	$	$	$	Rent	$
Overtime				First Mortgage (P&L)
Bonuses				Other Financing
Commissions				Hazard Insurance
Dividends/Interest				Real Estate Taxes
Net Rental Income				Mortgage Insur.
Other+ (Before completing, see notice under Describe Other Income below)				Homeowner Assn. Dues


Total	$	$	$		$

DESCRIBE OTHER INCOME
NOTICE + Alimony, child support, or separate maintenance income need not be revealed if the Borrower (B) or Co-Borrower (C) does not choose to have it considered as a basis for repaying this loan.
Item	Monthly Amount
	$

IF EMPLOYED IN CURRENT POSITION LESS THAN 2 YEARS COMPLETE THE FOLLOWING. THESE QUESTIONS APPLY TO BOTH BORROWER (B) and CO-BORROWER (C)
B/C	Previous Emplr./School	City/State	Type of Bus.	Position/Title	Dates	Monthly Income

THESE QUESTIONS APPLY TO BOTH BORROWER (B) and CO-BORROWER (C).
	B Y/N	C Y/N		B Y/N	C Y/N
If a yes answer is given to a question in this column, explain on an attached sheet.			Are you a co-maker or endorser on a note?
			Are you a party in a law suit?
Have you any outstanding judgments?			Are you obligated to pay alimony, child support, or separate maintenance?
In the last 14 years, have you been bankrupt?			Do you have health and accidental insurance?
Have you had property foreclosed upon or given title or deed in lieu of?			Do you have major medical coverage?

Liabilities and Pledged Assets. List the creditor's name, address and account number for all outstanding debts, including automobile loans, revolving charge accounts, real estate loans, alimony, child support, stock pledges, etc. Please contact the bank if there are more items than space provided.

Liabilities	Monthly Payment	Unpaid Balance
Name and address of Company	$	$
Acct. No.	$	$
Name and address of Company	$	$
Acct. No.	$	$
Name and address of Company	$	$
Acct. No.	$	$
Name and address of Company	$	$
Acct. No.	$	$
Name and address of Company	$	$
Acct. No.	$	$
Name and address of Company	$	$
Acct. No.	$	$
Alimony/Child Support/Separate Maintenance Payments Owed to:	$
Job Related Expense (child care, union dates, etc.)	$
Total Monthly Payments	$
	Total Liabilities b.

SCHEDULE OF REAL ESTATE OWNED (If Additional Properties Owned Attach Separate Schedule)
Address of Property	Type of Property Indicate S if Sold, PS if Pending Sale or R if Rental being held for income	Present Market Value	Amt. of Mortgages & Liens	Gross Rental Income	Mortgage Paymts.	Taxes, Ins., Maint. and Misc.	Net Rental Income
		$	$	$	$	$	$


Totals		$	$	$	$	$	$

LIST PREVIOUS CREDIT REFERENCES
Borrower or Co-Borrower	Creditor's Name and Address	Account Number	Purpose	Highest Balance	Date Paid




List any additional names under which credit has previously been received.

Disclosure

I understand that this is an application for an account and is subject to approval.

I/We certify that the information on this application is true and complete to the best of my/our knowledge. First Service Bank is authorized to verify, exchange and retain credit and employment information contained herein and relative to this application.

If you have any questions, please contact us at 800-669-2517 x293 or by e-mail at ebanking@1stservicebank.com. NOTE: Unlike this application form, emails sent to this address are not secure. Please DO NOT include any private or confidential information.

In order for us to process your application correctly, we may need to contact you to verify some of the information or request more necessary documentation. This information will also allow us to better satisfy our regulatory requirements to "KNOW YOUR CUSTOMER." We appreciate you supplying the information for that purpose.

SPECIAL NOTE: When opening any account with First Service Bank , we need to verify your identity to ensure the security of your private financial information. If this is needed, as is the case with most account types, a First Service Bank representative will call you requesting that you either fax/mail in the proper proof of identification or stop by any FSB location.

By clicking below, I hereby certify that everything I have stated above is correct. You may keep this application whether or not it is approved. By clicking below, I authorize you to check my credit and employment history and verify other information which I have provided to you.

PLEASE PRINT THIS APPLICATION USING THE BUTTON BELOW. YOU MAY FAX THIS APPLICATION TO:

Dermott: 870-538-3246
Greenbrier: 501-679-6461
Clinton: 501-745-7454
Marshall: 870-448-2030
Mountain View: 870-269-7211
Yellville: 870-449-7301
Flippin: 870-453-7301

OR bring your application to the branch location nearest you.