Preliminary Loan Application

By submitting this preliminary application, I/We certify that this information has been supplied truthfully, accurately and voluntarily, and therefore authorize Citizens Bank of the Midwest to investigate our creditworthiness, credit history, and financial responsibility through any credit bureau or by any other reasonable means for consideration for the loan applied for, or for any other services offered. 

This application does not constitute a contract for the extension of credit and is only a preliminary step in the loan approval process.  Additional information may be required before the final loan approval is granted.

Upon receipt of this application, someone at Citizens Bank of the Midwest will review your information and will get back with you to finalize the loan.

INSTRUCTIONS: Please complete as much as possible.

Will there be a co-applicant on this loan?*
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Personal Information

Are you married?*
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Residency Type*

If you have lived at your current residence less than two years, please provide your previous address:

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Employment Information

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Co-Applicant Personal Information

Are you married?
Please select a state.
Residency Type

If you have lived at your current residence less than two years, please provide your previous address:

Please select a state.

Co-Applicant Employment Information

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Income & Asset Information

Debt Information

Rent or Mortgage

Credit Cards



Automatic Loan Payments

Loan payments can be deducted automatically from your checking account. This item is optional, and we will contact you with full details about this method of payment if you select this option.

Automatic Loan Payments

To help the government fight the funding of terrorism and money laundering activities, federal law requires all financial institutions to obtain, verify, and record information that identifies each person who applies for a loan or opens an account. What this means for you. When you apply for a loan or open an account, we will ask for your name, address, date of birth and other information that will allow us to identify you. We may also ask to see your driver’s license or other identifying documents. In some instances, we may use outside sources to confirm the information. The information you provide is protected by our Privacy Policy and federal law.

You certify that everything you have stated in this Credit Application and on any other documents submitted to us are true and correct to the best of your knowledge. You understand that you must update the information contained in this Credit Application if either your financial condition materially changes or we make a request to you orally or in writing. You understand that we will retain this Credit Application whether or not it is approved.

You authorize us to request one or more consumer reports, to check and verify your credit and employment history, and to answer questions others may ask us about our credit experience with you.

You authorize us to contact you using any of the telephone numbers listed on this Credit Application or that you subsequently provide us in connection with your credit account – regardless whether the number we use is assigned to a paging service, cellular telephone service, specialized mobile radio service, other radio common carrier service or any other service for which you may be charged for the call. You further authorize us to contact you through the use of voice, text and email and through the use of prerecorded/artificial voice messages or an automatic dialing device.

This document is secured with encryption provided by your browser. Your information will be encrypted when using this form while in transit between your browser and Citizens Bank of the Midwest.

By submitting this form, you further agree that you viewed and read the entire Credit Application and notices before you submitted it.  You understand that this Credit Application is in the electronic form that we will keep.  We may rely on, and enforce, this Credit Application in the electronic form or as a paper version of the electronic form.

Notice: It is a federal crime punishable by fine, imprisonment, or both, to knowingly make any false statements concerning any of the above facts as applicable under the provisions of Title 18, United States Code § 1001, et seq.

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