CREDIT APPLICATION IMPORTANT: Please readthese directions before completingthis Application, and check (*^) the appropriate box below.

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1 Closed End. ecured/unsecured Credit CREDIT APPLICATION IMPORTANT: Please readthese directions before completingthis Application, and check (*^) the appropriate box below. If you are applying for individual credit in your own name, and are 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 complete only ections AandD. Iftherequested credit isto besecured, alsocomplete thefirst part ofection Candection E. Ifyou are applying for joint credit with another person, complete all ections except E. providing information in Babout the joint applicant. Ifthe requested credit is to be secured then complete ection E WE INTEND TO APPLY FOR JOINT CREDIT:,, ,. APPLICANT CO-APPLICANT It you are applying for individual credit, but are relying on income from alimony, child support, orseparate maintenance oron the income orassets of another person asthe basis for repayment of the credit requested, complete all ections except Etothe extent possible, providing information in Babout the person on whose alimony, support, ormaintenance payments orincome orassets you are relying. Ifthe requested credit is to be secured, then completeection E. IMPORTANT INFORMATION ABOUT PROCEDURE FOR OPENING A NEW ACCOUNT To help the government fight the funding ofterrorism and money laundering activities, the UA Patriot Act requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. What this means for you: When you open an account, we will ask for your name, physical address, date of birth, taxpayer identification number and other information that will allow us to identify you We may also ask to see your driver's license orother identifying documents. We will let you know if additional information is required AMOUNT REQUETED PAYMENTDATEDEIRED ECTION A - INFORMATION REGARDING APPLICANT FULL NAME (Last.FitsiMiddle) PROCEED OFCREDIT TOBEUED FOR BUINE PHONE Ext. IF U.. ON: DRIVER LICENENO. TATE ID CARD NO. TATE DATE OF IUANCE DATEOF IUANCE DATEOF EXPIRATION DATEOF EXPIRATION OTHER (MILITARY ID.TRIBAL ID.ETC.) OCIALECURITYNO. or TAXID NO IF NON U.. ON: DRIVER LICENEf.C DATE OF IUANCE DATE OF EXPIRATION OCIALECURITY NO ot TAXI D NO TATE ID CARD NO DATEOF IUANCE DATE OFEXPIRATION PAPORTNO.& COUNTRYOf IUANCE (INDIVIDUAL TAXPAYER ID NO NO TAXPAYER ID NO.BUT HAVE FILED IGOVERNMENT IUED DOCUMENT NO APPLICATION FORONE.WHENFILED: ANDCOUNTRY OFIUANCE: PHYICAL REIDENTIAL OR BUINE TREET ADDRE AND MAILING ADDRE (treet. PO Box. City. tate. &Zip) or:if MILITARY APO OR FPO ADDRE or:if N'A, NEXT OF KIN OR FRIEND HOW LONGAT PREENT ADDRE? PREVIOU ADDRE (treet. City.tale. & Zip) HOW LONGAT PREVIOU ADDRE? ADDRE PREENT EMPLOYER (Company Name&Address) POITION OR TITLE HOWLONGWITH PREENT EMPLOYER? NAMEOF UVIOR PREVIOU EMPLOYER (Company Name & Address) HOW LONGWITH PREVIOU EMPLOYER? YOUR PREENTGRO ALARYOR COMMIION YOUR PREENT NET ALARY OR COMMIION NO DEPENDENT AGE OF DEPENDENT Alimony, child support, or separate maintenance income need not be revealed il you do not wish to have itconsidered as a basis for repaying this obligation. Alimony, child support, or separate maintenance received under: D Court Order D Written Agreement Oral Understanding OTHER INCOME $ OURCE OF OTHER INCOME Isanyincomelistedinthis ection likely to be No reduced before the credit requested is paid off? Yes (Explain) Checking Acct. No. Haveyou ever received No credit from us? Yes- When? avings Acct. No. NAME 4 ADDREOFNEARETRELATIVE NOTLIVING WITHYOU REIATIONHIP TELEPHONE NO. (IncludeAreaCode) ECTION B - INFORMATION REGARDING JOINT APPLICANT OR OTHER PARTY (Use separate sheets ifnecessary.) FULL NAME (Last. Firsl. Middle) RELATIONHIP TO APPLICANT illany) IBIRTH DATE HOME PHONE BUINE PHONE IF U.. ON: DRIVER LICENE NO TATE IDCARD NO TATE DATE OF IUANCE DATEOr IUANCE DATE OF EXPIRATION DATEOF EXPIRATION OTHER (MILITARY ID,TRIBAL ID.ETC.) OCIAL ECURITY NO. or TAX ID NO. IF NON U.. ON: DRIVER LICENENO. DATEOFIUANCE DATEOFEXPIRATION OCIAL ECURITYNO or TAXID NO TATE IDCARD NO. TATE DATEOF IUANCE DATE OF EXPIRATION PAPORTNO. &COUNTRY OFIUANCE: INDIVIDUAL TAXPAYER ID NO NU TAXPAYER IDNO.. BUI HAVEFILEO APPLICATION FOR ONE WHEN FILED. GOVERNMENTIUED DOCUMENTNO. ANDCOUNIRYOF IUANCE: PHYICAL REIDENTIAL OR BUINE TREET ADDRE AND MAILING ADDRE (lreel, POBox, City. tate.&zip) or:if MILIIARY, APO OilIPOADDHI or.if N'A. NEXT OT KIN OR FRIEND OTHER HOW LONGAT PREENT ADDRE? PREENT EMPLOYER (CompanyName & Address) PREVIOU EMPLOYER (Company Name&Address) OCCUPATION POITION OR TITLE HOW LONG WITH PREENT EMPLOYER? NAME OF UVIOR HOW LONGWITH PREVIOU EMPLOYER? YOUR PREENT GRO ALARY OR COMMIION YOUR PREENT NET ALARY OR COMMIION NO. DEPENDENT AGE OF DEPENDENT $ 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. Alimony, child support, orseparate maintenance received under: D Court Order D Written Agreement D Oral Understanding OTHERINCOME OURCE OF OTHERINCOME Is anyincome listed in this ection likely to be No reduced beforethe credit requested is paidoff? Yes (Explain) NAME& ADDRE OFNEARET RELATIVENOT LIVINGWITH YOU Checking Account No. avings Account No. Has Joint Applicantor Other Party No ever received credit from us? D Yes - When? TELEPHONE NO. (IncludeAreaCode) ECTION C - MARITAL TATU (Do not complete if this is an Application for individual unsecured credit.) APPLICANT Married eparated Unmarried (Including single, divorced, orwidowed) OTHER PARTY D Married D eparated Unmarried (Including single, divorced, orwidowed) Copyright : Professional Bank Forms Co.: Box 759; Oxford, K67119 Form 501 CD- 9/03

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