Secure Online Banking


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Visa® Credit Card

Florida Parishes Bank Secure Loan Application
Florida Parishes Bank applications are private and secure.

Please provide all the requested information. When you have completed the form, press the Submit button to send your application. If necessary, we will contact you for additional information.

The items marked with (*) are required fields.


Disclosures

*I Accept the Disclosures

General Information

Will you be applying for Individual or Joint Credit?
Joint
Individual

(If Joint, the co-applicant section has the same required fields as the primary applicant.)

Marital Status: Complete marital status if this loan is for:

a. Joint or secured credit, or
b. You reside in or rely on property located in a Community Property State. (AZ, CA, ID, LA, NM, NV, TX, WA, WI)
Unmarried
Married
Separated
This application is not for joint or secured credit and I do not live in the states listed above.

*Type of Card Requested

*Number of Cards Requested

*Limit Requested

$

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Primary Applicant

*Do you have an account with us?

Yes No
*Last Name
*First Name
Middle Name
*Social Security Number (TIN) --
*Date of Birth //
Number of Dependents
Ages of Dependents
*Home Phone Number
Work Phone Number - - ext.
Number - -ext.
Email Address
Drivers License #
Drivers License State

Home Address

*Address 1
Address 2
*City
*State *Zip -
Time at Current Residence
Years Months
Residence Type Own Rent Other

Previous Address

Address 1
Address 2
City
State Zip -
Time at Previous Residence
Years Months
Residence Type: Own Rent Other

Present Employer

Name
Phone Number - - ext.
Employment Status
Full Time
Part Time
Temp
Retired
Other
Job Title
Job Start Date //
Gross Salary
$ Per

Alimony, child support, or separate maintenance need not be revealed if you do not wish to have it considered as a basis for repaying obligation.

Other Income
$ Per
Other Income Source

Previous Employer

Name
Phone Number - - ext.
Employment Status
Full Time
Part Time
Temp
Retired
Other
Job Title
Job Start Date //
Job End Date //
Gross Salary $ Per

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Co-Applicant

*Do you have an account with us?
Yes No
*Last Name
*First Name
Middle Name
*Social Security Number (TIN) --
*Date of Birth /
Number of Dependents
Ages of Dependents
*Home Phone Number --
Work Phone Number -- ext.
Number - -ext.
Email Address
Drivers License #
Drivers License State

Home Address

*Address 1
Address 2
*City
*State *Zip -
Time at Current Residence
Years Months
Residence Type
Own Rent Other
Monthly Payment
$

Previous Address

Address 1
Address 2
City
State
Zip -
Time at Previous Residence
Years Months
Residence Type Own Rent Other

Previous Employer

Name
Phone Number -- ext.
Employment Status Full Time Part Time Temp Retired Other
Job Title
Job Start Date //
Gross Salary $ Per

Alimony, child support, or separate maintenance need not be revealed if you do not wish to have it considered as a basis for repaying obligation.

Other Income $ Per
Other Income Source

Previous Employer

Name
Phone Number -- ext.
Employment Status
Full Time Part Time Temp Retired Other
Job Title
Job Start Date //
Job End Date //
Gross Salary $ Per

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References

Nearest relative Not Living With You

Last Name
First Name
Relationship
Number -- ext.
Address 1
Address 2
City
State
Zip -

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Additional Information


How would you prefer to be contacted?
Home Phone
Work Phone
Cell Phone
Email Address
Other
Please add me to your email list.
Special Instructions/Comments

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PLEASE READ THE FOLLOWING CAREFULLY BEFORE SIGNING: This statement is submitted to obtain credit and I/we certify that all information herein is true and complete. I/We agree that inquiries may be made to verify information and that credit references or verifiation may be given based on inquiries from other parties. This offer is subject to the credit policies of this institution. I/We agree to be bound by the terms and conditions of the cardholder agreement, a copy of which will be mailed to the applicant if this application is granted, receipt of such agreement and acceptance of such terms to be conclusively presumed by the applicant’s use. If you intend to apply for joint credit, the undersigned shall be jointly and severally liable for any and all credit extended from time to time. We may report information about your account to the credit bureaus. Late payments, missed payments, or other defaults on your account may be reflected in your credit report.