Midland National Bank
527 N. Main Street, P.O. Box 427
Newton, Kansas 67114
(316) 283-1700 / (800) 810-9457
Member FDIC  /  Equal Housing Lender

PLEASE NOTE: Midland National Bank is located solely within the state of Kansas, county of Harvey, USA. Our natural trade area includes Harvey county and all neighboring counties (Sedgwick, Reno, Butler, McPherson and Marion). If you are not within our immediate trade area, please call us at (316) 283-1700 to request further information.
PERSONAL CREDIT APPLICATION
Individual Credit Joint Credit

Click here if you are applying for individual credit. This means you are applying in your own name and are relying on your own income or assets, NOT those of another person as the basis for repayment.

Click here if you are applying for joint credit with another person and will be relying on both your and their income or assets as the basis for repayment. (please initial below)
   We intend to apply for joint credit.
  Applicant's initials:

(please initial)
  Co-Applicant:

(please initial)
Please complete only the "Applicant Information" section. Please complete both the "Applicant Information" and the "Co-Applicant Information" sections.
Requested Loan Amount (required) : $   Purpose of Loan (required):  
If Purpose of Loan involves a vehicle,
please provide the Year, Make, Model and Mileage:
Loan officer preference:
 I. Primary Borrower Information
Primary Borrower's Name:   Date of Birth:  
Social Security Number:    Years of School:
If applying for secured credit, please indicate marital status: Married   Unmarried  Separated
Number of Dependents:   Ages of Dependents:  
Present Address:   City:   State:   Zip Code:
Years at Present Address:  Own  Rent   Home Phone:   E-mail Address:

Previous Address:
City:   State:   Zip Code: Years at Previous Residence:   Owned   Rented

Current Employment Information
Present Employer: Self Employed
Employer Address: Employer City:   State:   Zip Code:
Employer Phone: Years with Present Employer:   Title:
Start Date:   Monthly Gross Income: $

Previous Employment Information
Previous Employer:   Self Employed
Previous Employer Address: City:   State:   Zip Code:
Previous Employer Phone: Years with Previous Employer:   Title:
Start Date:   End Date:   Monthly Gross Income: $

Other Income Information
Other Income Amount: $   Weekly   Monthly   Yearly
Source of Other 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.

Do you presently pay:

Type Amount Weekly Monthly
Alimony
Support
Maintenance
 II. Co-Borrower Information
Co-Borrower's Name:   Date of Birth:
Social Security Number:    Years of School:
If applying for secured credit, please indicate marital status: Married  Unmarried  Separated
Number of Dependents:   Ages of Dependents:
Present Address: City:   State:   Zip Code:
Home Phone:   E-mail Address:
Years at Present Address:  Own    Rent

Previous Address: City:   State:   Zip Code:
Years at Previous Residence:    Owned   Rented

Current Employment Information
Present Employer: Self Employed
Employer Address: Employer City:   State:   Zip Code:
Employer Phone: Years with Present Employer:   Title:
Start Date:   Monthly Gross Income: $

Previous Employment Information
Previous Employer: Self Employed
Previous Employer Address: City:   State:   Zip Code:
Previous Employer Phone: Years with Previous Employer:   Title:
Start Date:   End Date:   Monthly Gross Income: $
 III. Primary Borrower's Insurance Information
Please complete the following section if securing this loan with a vehicle or property.
Insurance Agent:   Insurance Agent Telephone:
Insurance Agent Address:   City:   State:   Zip:
 IV. Primary Borrower & Co-Borrower Asset & Debt Information
Assets: List all debts to banks, loan or finance companies, charge accounts, and installment purchases. Include debts on which applicant is a co-maker, endorser, or guarantor.
Bank Accounts
Bank Name / Address Account # Current Balance
1.
2.
3.
Automobiles
Automobile Make / Model Year Current Value
1.
2.
3.
4.
Stocks, Bonds & Other Assets
Stocks and Bonds Description: Value:
Retirement Accounts: Value:
Other Assets: Value:
Liabilities:
Company / Debtor Account # Monthly Payment Unpaid Balance
 V. General Information
If you or a joint applicant or other party answers "yes" to any of the following questions, please explain in the space provided.
Are you a guarantor or co-maker of any leases, contract or debts? Borrower: Yes   No
Co-Borrower:  Yes  No

If yes, please explain:

Are there any suits or judgments against you? (Include amount) Applicant:  Yes   No  
Joint Applicant: Yes    No

If yes, please explain:

Have you been declared bankrupt in the last 10 years? Applicant:   Yes   No
  Joint Applicant:  Yes   No

If yes, please explain:

 VI. Agreement & Authorization
CREDIT DISCLOSURES: An insurance product may be offered with this product. If an insurance product is offered an extension of credit cannot be conditioned on either of the following: (1) Your purchase of an insurance product from this Bank or any of our affiliates; or (2) Your agreement NOT to obtain, or a prohibition on you from obtaining, an insurance product from an unaffiliated entity. By signing this Application you agree that you have read and understand these Disclosures.
Applicant Signature:       Date:
Joint Applicant Signature:    Date:
By clicking the "Submit Application" button below, I certify that everything I have stated in this application and on any attachments is correct.  The Bank may keep this application whether or not it is approved.  By typing and submitting this form, I authorize Midland National Bank to check my credit and employment history, to have a consumer credit report prepared on me for the purpose of evaluating this application for credit, and to answer questions others may ask about my credit record with Midland. Midland National Bank may rely on such information to make credit decisions concerning my loan. I agree to notify Midland National Bank of any adverse change in my financial condition.