Consumer Loan * indicates a required field Type of Credit Requested IMPORTANT: Check the appropriate boxes below and complete the applicable sections Type Of Credit: ** Please Select ** Secured Unsecured Individual or Joint Credit: ** Please Select ** Individual Credit-relying solely on my income or assets Individual Credit-relying on my income or assets as well as income or assets from other sources Joint Credit * Amount Requested?: $      * For How Long?:      * Payment Date Desired:      Want To Repay: Monthly Other, please specify:   * Proceeds of loan to be used for:      Section A - Individual Applicant Information * Name (First, Middle, Last):             * Date of Birth:      * Home Phone Number:      * Driver's License Number:      * Social Security Number:      Number of Dependents and Ages:   * Address including City, State, Zip, and County:      * Email:      * Do you rent or own? Own    Rent    * How Long? (Specify years or months):      Previous Address including City, State, Zip, and County:   How Long? (Specify years or months):   * Name of Nearest Relative Not Living With You:      * Relationship:      * Nearest Relative Address:      * Relative Phone No.:      * Your Employer:      * Employer Address:      * How Long? (specify years or months):      * Business Phone Number:      * Position:      * How Often Paid:      * Gross Salary per Month:      Previous Employer:   Address:   How long were you employed? (specify years or months):   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, separate maintenance received under: Alimony Child Support Seperate Maintenance Sources Of Other Income:   Amount per Month: $   Is any income listed in this section likely to be reduced before the credit request is paid off? No Yes, please explain:   Have you previously received credit from us? No Yes-When?   Section B - Joint Applicant or Other Party Information Complete only if: for joint credit, for individual credit relying on income or assets from other sources, or applicant is married and resides in a community property state. Name (First, Middle, Last):       Date of Birth:   Home Phone Number:   Driver's License Number:   Social Security Number:   Email:   Relationship To Applicant (if any):   Number of Dependents and Ages:   Address including City, State, and Zip:   How Long? (Specify years or months):   Employer:   Employer Address:   How Long? (specify years or months):   Business Phone Number:   Position:   How Often Paid:   Gross Salary per Month:   Previous Employer:   Address:   How long were you employed? (specify years or months):   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, separate maintenance received under: Alimony Child Support Seperate Maintenance Sources Of Other Income:   Amount per Month: $   Is any income listed in this section likely to be reduced before the credit request is paid off? No Yes, please explain:   Have you previously received credit from us? No Yes-When?   Section C - 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: Married Separated Unmarried (including single, divorced, and widowed) Other Party: Married Separated Unmarried (including single, divorced, and widowed) Section D - Asset and Debt Information Assets Owned If Section B has been completed, this Section should be completed giving information about both the Applicant and Joint Applicant or Other Person. Please mark Applicant-related information with an "A." If Section B was not completed, only give information about the Applicant in this Section. Description of Assets Name in Which the Account is Carried Subject to Debt? Value Checking Account (Account Number, Where)             Yes No $        Yes No $  Savings Account (Account Number, Where)             Yes No $        Yes No $  Certificates of Deposit(s) (Account Number, Where)             Yes No $        Yes No $  Marketable Securities (Issuer, Type, No. Shares)               Yes No $          Yes No $  Real Estate (Location, Date Acquired mm/dd/yyyy)             Yes No $        Yes No $  Life Insurance (Issuer, Face Value)             Yes No $        Yes No $  Automobiles (Make, Model, Year)           Yes No $      Yes No $  Other (list)           Yes No $      Yes No $  TOTAL ASSETS       Outstanding Debts (Include charge accounts, installment contracts, credit cards, rent, mortgages, and other oblligations.) Creditor Account Number Name in Which the Account is Carried Original Amount Present Balance Monthly Payments Landlord or Mortgage Holder ** Please Select ** Rent Mortgage (Omit Rent) (Omit Rent)       $  $  $  Automobiles (describe)       $  $  $        $  $  $  Other (describe)       $  $  $        $  $  $        $  $  $  TOTAL DEBTS $  $  $  Complete the following information about both the applicant and Joint Applicant or Other Person (if applicable). Also, please don't use commas or dollar signs in the dollar amount fields: Are you obligated to make Alimony, Support, or Maintenance Payments? ** Please Select ** YES NO If yes, to (Name & Address)   Amount per month $   Are you a co-maker, endoser or guarantor on any loan or contract? ** Please Select ** YES NO If yes, for whom?   To Whom?   Are there any unsatisfied judgements against you? ** Please Select ** YES NO If yes, to whom owed?   Amount $   Have you been declared bankrupt in the last 10 years? ** Please Select ** YES NO If yes, where?   Year?   Section E - Secured Credit Complete only if credit is to be secured. Briefly describe the property to be given as security. Property Description:   Name and Address of Property Owner 1   Name and Address of Property Owner 2   Name and Address of Property Owner 3   Which branch will you be opening your loan at? ** Please Select ** Broadway Office (Main Office) Pennsylvania Avenue Office Mount Bethel Office Wind Gap Office Forks Township Office Easton Business Center Martins Creek Office Nazareth Office   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 signing below 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 credit information at your request if my financial condition changes. Merchants Bank is committed to meeting the financial needs of consumers & small businesses primarily in Northampton and Lehigh Counties, however, Bucks and Monroe counties as well as parts of Western New Jersey are considered in our trade area.