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* Required Field

Personal Information

First Name*

Middle Name

Last Name*

Street Address*

City*

State*

Zip Code*

Date of Birth*

Time at Present Address

Mother's Maiden Name

Property Type*

Rent
Own/Mortgage
Board

Monthly Payment*

Home Phone Number*

Cell Phone Number

Social Security Number*

Email Address

Employment and Income

Present Employer (Company Name)*

Business Telephone Number

Employer Street Address

City

State

Zip Code

Current Position*

Time with the Company

Annual Salary*

Other Household Income

Total Household Income

Source of Other Income

Previous Employer (if less than 2 years at present)

Time There With This Company

Rewards Enrollment

Enroll in Rewards?*

Enroll
Do Not Enroll

Joint Applicant Information

First Name

Middle Name

Last Name

Street Address

City

State

Zip Code

Cell Phone Number

Date of Birth

Time at Present Address

Mother's Maiden Name

Property Type

Rent
Own/Mortgage
Board

Monthly Payment

Social Security Number

Home Phone Number

Joint Applicant - Employment

Present Employer (Company Name)

Business Telephone Number

Employer Street Address

City

State

Zip Code

Current Position

Time with the Company

Annual Salary

Other Household Income

Total Household Income

Source of Other Income

Personal Reference

Name of a Close Friend or Relative Not Living With You

Employer Street Address

City

State

Zip Code

Home Phone Number

Cell Phone Number

Disclosure and Signature

Authorization: I certify that I am at least 18 years of age, and that I have read and agree to all the terms, authorizations and disclosures contained on the attached form and that everything I have stated in this certificate is true and correct. I authorize Farmers Bank & Trust Company to check my credit report and to verify my credit, employment, and income references. I understand that the use of any card issued in conjunction with this offer will constitute my acceptance of and will be subject to the terms and conditions of this Card Agreement. I understand that the terms of my account are subject to change as provided in this Card Agreement.

Applicant Signature*

Applicant Date*

Joint Applicant Signature

Applicant Date

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