EmailMe Form - Consumer or Business w/ Consumer Application

Simple Interest Bank
Financing! (W.A.C.)

PRIMARY CREDIT APPLICANT INFORMATION SECTION:

First Name *

Middle Initial *

Last Name *

Home/Cell Phone *

### - ### - ####

Email *

CONFIRMATION EMAIL RESPONSE

Birthdate *

MM / DD / YYYY

Social Security # *

Number Only-No Dashes

Current Address *

Street Address City State / Province / Region Postal / Zip Code

Years at Address *

Payment Per Month $ *

Rent or Own *

Rent

Own

PRIMARY APPLICANT EMPLOYMENT INFORMATION SECTION FOR LOAN:

Application Type: *

1. Individual - Primary Applicant Only

2. Business w/ Primary Applicant

Employer Name *

Job Title *

Employer Phone *

### - ### - ####

Years at Job *

Gross MONTHLY Income $ *

Proof of Income may be required

FED ID # (Only if adding Business to Loan)

Number Only-No Dashes-

CO-APPLICANT INFORMATION

Add Co Applicant? *

1. NO

2. YES

First Name: *

Middle Initial:

Last Name: *

Social Security # *

Number Only-No Dashes

Birthdate *

MM / DD / YYYY

Co-Applicant Relationship to Primary Applicant: *

Spouse

Relative

Employer Name *

Job Title *

Employer Phone *

### - ### - ####

Years at Job *

Gross MONTHLY Income $ *

Proof of Income may be required

Canfield Equipment Inventory being Financed:

Vehicle Type *

MFG / Model

Chevy / 1500

Year

New or Used: *

New

Used

Amount Requested $ *

E-Sign Act Notice Of Delivery Of Disclosures

Federal regulation requires financial institutions to inform loan applicants that certain disclosures related to this on-line application will be delivered electronically (e.g., screen display). Should the application be denied, Notice of Adverse Action will be sent to the applicant(s) via U.S. Postal Service. Should the application be approved and applicant(s) process a loan with us through the dealership of their choice, copies of loan-related disclosures will be provided to them by the dealership where the transaction is completed. Applicants must agree to this notice for the application process to continue.

CREDIT AUTHORIZATION: I/WE HEREBY AUTHORIZE AND SUBMIT TO CAMM FINANCIAL, ITS DESIGNEES, ASSIGNS OR POTENTIAL ASSIGNS TO REVIEW MY/OUR PERSONAL AND/OR BUSINESS CREDIT PROFILE PROVIDED BY NATIONAL CREDIT BUREAUS IN CONSIDERING THIS APPLICATION AND FOR THE PURPOSE OF UPDATING, RENEWING, GRANTING THE EXTENSION OF CREDIT OR ADDITIONAL CREDIT OR THE COLLECTION OF ANY LATE ACCOUNTS AND THE DECISION IS THAT OF THE FINANCIAL INSTITUTION, NOT CAMM FINANCIAL. I/WE HEREBY AUTHORIZE OUR REFERENCES TO RELEASE CREDIT INFORMATION AND I/WE REPRESENT AND WARRANT THAT THE INFORMATION SUBMITTED HEREIN IS TRUE, COMPLETE AND ACCURATE. A FACSIMILE, ELECTRONIC OR OTHER COPY OF THE AUTHORIZATION SHALL BE AS A VALID ORIGINAL.

Applicant(s)/Buyer(s): *

TYPE NAME as will be written below

Signature Of Applicants(s) *

Clear

Beside * Above. (Use mouse (press & hold left button and release when done) and sign your signature - Digital Signature to Authorize) APPLICANT HAS THE AUTHORITY TO SUBMIT THIS APPLICATION BY SIGNING MY/OUR NAME(s) AND CHECKING - "I AGREE" TO SUBMIT AND AUTHORIZE APPLICATION FOR CREDIT REVIEW.

I/WE Confirm *

I Agree & Authorize