TO REPORT A LOST OR STOLEN VISA CHECK CARD AFTER NORMAL
BANKING HOURS, PLEASE
CALL
1-800-523-4175
The form can
only be processed with your signature. Enter the information
in the application, print, sign and return to any Glennville
Bank location..
Will there be a co-applicant on this application?
Yes
No
Type of loan requested:
Amount requested:
Primary Applicant
Last Name:
First Name:
SSN:
Date of Birth:
Address:
City:
State:
Home Phone:
Zip Code:
Email Address:
Employer's Name:
Employer's Phone:
Job Start Date:
(Month / Year)
Gross Income:
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.
Hourly
Monthly
Annually
Job Title:
In addition to Rent/Mortgage, list all
other debts (for example auto loans, credit
cards, second mortgage, alimony, child support, child
care, medical utilities, auto
insurance, IRS liabilities, etc.). Please use a separate
line for each credit card
and auto loan.
Income verification is required; therefore,
other information may be necessary.
Debts
Monthly Payment
Joint Applicant (if applicable)
Last Name:
First Name:
SSN:
Date of Birth:
Address:
City:
State:
Home Phone:
Zip Code:
Email Address:
Employer's Name:
Employer's Phone:
Job Start Date:
(Month / Year)
Gross Income:
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.
Hourly
Monthly
Annually
Job Title:
In addition to Rent/Mortgage, list all other debts
(for example auto loans, credit
cards, second mortgage, alimony, child support, child
care, medical utilities,
auto insurance, IRS liabilities, etc.). Please use
a separate line for each credit
card and auto loan.
Income verification is required; therefore, other
information may be necessary.
Debts
Monthly Payment
I certify that statements on this application
are true and complete. I authorize any person,
association, firm or corporation to furnish, on request
of Online Financial Institution, any
information concerning my affairs or me. Sec. 1014,
Title 13, U.S. Code, makes it a Federal
Crime to knowingly make a false statement on this
application.
Signature ___________________________________ Date
________________
Glennville
Bank
102 East Barnard Street
Glennville, Georgia 30427
(912) 654-3471 * Fax (912) 654-1517
Ludowici Bank
5 Cypress Street
Highway 84 East
Ludowici, Georgia 31316
(912) 545-2530 * Fax (912) 545-3334
