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Credit Application - Please fill out online, print, and bring in to our offices.
Type of Credit Requested:
Secured
Unsecured
Individual Credit - relying on my income or assets
Individual Credit - relying on my income or assets as well as income or assets from other sources
Joint Credit

Century Bank
of Georgia
P.O. Box 580
Cartersville, GA 30120

Date of Application:
Amount $
How Long:
Payment Date Desired:
Want to Repay Monthly ______
Acct. No.
Class:
Section A - Individual Applicant Information
Name: Last: M.I.: First:
Birth Date: Tel. No. Soc. Sec. No.
Present Address: City: State: Zip:
County: How Long
Previous Address: City: State: Zip:
County: How Long
Have you applied for credit with us before? No Yes
If Yes, then when? No. Dep. Dep. Ages
Name of Nearest Relative Not Living With You: Relationship
Address: Tel. No.
Employer (Company Name & Address) How Long
Bus. Tel. Position/Title How Often Paid? Gross Monthly Income $
Previous Employer (Company Name & Address) How Long

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.

Alimony, child support, separate maintenance received under: Court Order Written Agreement Oral Understanding

Sources of Other Income: Amount Per Month:

Section B - Joint Applicant or Other Party Information
Complete only if: for joint credit, for individual credit relying on income of assets from other sources, or applicant is married and resides in a community property state.
Name: Last: M.I.: First:
Birth Date: Tel. No. Soc. Sec. No.
Present Address: City: State: Zip:
County: How Long
Previous Address: City: State: Zip:
County: How Long
Have you applied for credit with us before? No Yes
If Yes, then when? No. Dep. Dep. Ages
Name of Nearest Relative Not Living With You: Relationship
Address: Tel. No.
Employer (Company Name & Address) How Long
Bus. Tel. Position/Title How Often Paid? Gross Monthly Income $
Previous Employer (Company Name & Address) How Long

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.

Alimony, child support, separate maintenance received under: Court Order Written Agreement Oral Understanding

Sources of Other Income: Amount Per Month:

Section C - Marital Status

Complete only if: for joint or secured credit, or applicant resides in a community property state or is relying on property located in such a state. (*Includes single, divorced and widowed)

Applicant: Married Separated Unmarried* Applicant: Married Separated Unmarried*
Section D - Asset & Debt Information
If Section B has been completed, this Section should be completed giving information about both the Applicant and the Joint Applicant or Other Person. Please mark Applicant-related information with an "A". If Section B was not completed, only give information about the Applicant in this Section.
ASSETS OWNED (Use separate sheet if necessary.)
DESCRIPTION OF ASSETS NAME IN WHICH THE ACCOUNT IS CARRIED VALUE
Checking Account Number (s)





 





$
$
$
$
$
TOTAL ASSETS:   $

OUTSTANDING DEBTS: (include charge accounts, installment contracts, credit cards, rent, mortgages and other obligations.
(Use separate sheet if necessary.)
CREDITOR ACCOUNT NUMBER NAME THE ACCT. IS UNDER ORIGINAL AMT. PRESENT BAL MO. PMTS.
Landlord or Mortgage Holder
Rent Payment
Mortgage
(OMIT RENT)
$
(OMIT RENT)
$

$
Automobiles
(make, model, year)
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
TOTAL DEBTS $ $ $
Complete the following information about both the Applicant and Joint Applicant or Other Person (if applicable):
Are you obligated to make Alimony, Support of Maintenance Payments? No Yes
If yes, to (Name & Address) Amt. Per Month $
Are you a comaker, endorser, or guarantor on any loan or contract? No Yes
If yes, for whom? To whom?
Are there any unsatisfied judgments against you? No Yes
If yes, to whom owed? Amount: $
Have you been declared bankrupt in the last 10 years? No Yes If yes, where? Year
Section E - Secured Credit
Complete only if credit is to be secured. Briefly describe the property to be given as security and indicate if others have an ownership interest.
Property description:
Names & Addresses of all co-owners of the property:
If the security is real estate, give the full name of your spouse (if any):
Signatures - I certify that everything I have stated in this application and on any attachments is correct. You may keep this application whether or not it is approved. By signing below I authorize you to check my credit and employment history and to answer questions others may ask you about my credit record with you. I understand that I must update credit information at your request if my financial condition changes.
____________________________ ____________________________________
Applicants Signature Other Signature (Where Applicable) and Date
____________________________ ____________________________________
Date Date