Credit Application*

Applicant's Name (First, Middle, Last):

Co-Applicant's Name (First, Middle, Last) (Provide if you are applying for joint credit):

Information About Applicant – Please complete all fields.

Street Address (No P.O. Boxes):

City:
   State:    Zip:

Social Security #:
        Date of Birth:

Applicant:    Rents     Owns    Rent or Mortgage Payment :

If Applicant owns or is buying:
Home Value     Mortgage Balance

Time at Address (Years/Months):

Home Phone Number:

Mailing Address (If different from Street Address):

City:
   State:    Zip:

Employer:

How Long (Years/Months):    Salary: per year

Position:
   Work Phone :

Annual Household Income: Income from alimony, child support, or separate maintenance payments need not be disclosed if you do not wish to have it considered as a basis for repaying this obligation.

$ Per Year/Source:

Other Income: Income from alimony, child support, or separate maintenance payments need not be disclosed if you do not wish to have it considered as a basis for repaying this obligation.

$ Per Year/Source:

Email Address – If you provide an email address, Citicorp Trust Bank, fsb, may use it to contact you about your account. It may also use your email addres to send you informaton about products and services you might find useful:

Information About Co-Applicant

Street Address (No P.O. Boxes):
Same as Applicant?   Yes    

City:
   State:    Zip:

Social Security #:
        Date of Birth:

Home Phone Number:

Mailing Address (If different from Street Address):

City:
   State:    Zip:

Employer:

How Long (Years/Months):    Salary: per year

Position:
   Work Phone :

Applicant and Co-Applicant agree to the terms:    Yes     No

*This is a preliminary application. All information will be kept strictly confidential and not given out to any other third party.