Fidelity Bank --- Consumer Loan Application

Call 1 800 581 5363 to apply by Phone, or Fax to the Fidelity Bank office nearest you. Applications also accepted by Mail, or in Person at any location.
675 Main St Fitchburg Fax 978 343-2031	29 Main St Leominster Fax 978 537-0569	330 Main St. Gardner Fax 978 632-0430	25 Main St Shirley Fax 978 425-4358	97 Elm St Millbury Fax 508 865-0940

Individual Joint
Applicant 1			Applicant 2
Name	Phone Number		Name	Phone Number
Address	Years There		Address	Years There
City	Zip		City	Zip
	Own Rent			Own Rent
Date of Birth	Social Security #		Date of Birth	Social Security #
Number of Dependents Nearest Relative not living with you Address			Number of Dependents Nearest Relative not living with you Address

Previous Address (if less than 2 years at current address)	Years There		Previous Address (if less than 2 years at current address)	Years There
Current Employer			Current Employer
Employer's Address			Employer's Address
Years There	Employer Phone Number		Years There	Employer Phone Number
Gross Monthly Income	Current Position		Gross Monthly Income	Current Position
If self employed, provide 2 most recent tax returns			If self employed, provide 2 most recent tax returns
Previous Employer (if less than 2 years at current employer)	Years There		Previous Employer (if less than 2 years at current employer)	Years There
Other Income Source (If you do not wish to rely on alimony, child support, or seperate maintenance for repayment of this loan, such income need not be revealed.)	Source Amount		Other Income Source (If you do not wish to rely on alimony, child support, or seperate maintenance for repayment of this loan, such income need not be revealed.)	Source Amount
Obligation to pay Alimony, Child Support, or Maintenance Yes No Amount per week month			Obligation to pay Alimony, Child Support, or Maintenance Yes No Amount per week month
Your Bank Name	Account #	Balance	Your Bank Name	Account #	Balance
Checking			Checking
Savings			Savings
Home Purchase Price	Year Purchased	Approx. Market Value	Home Purchase Price	Year Purchased	Approx. Market Value
Credit References: Please list any banks, loan or finance companies that you now owe. List all other bills over $100. If none, state none. Give names of two (2) credit references whom you have paid on a monthly basis. Indicate: A - Applicant C - Co-Applicant J - Joint

A/C/J	Name of Creditor	Address	Type of Acct.	Outstanding Balances (if any)	Present Monthly Payments
A C J
A C J
A C J
A C J
A C J
A C J

Have you ever filed bankruptcy? Yes No If yes, year			Have you ever filed bankruptcy? Yes No If yes, year
Are you a a Co-Maker, Endorser, or Guarantor on any loan or contract? Yes No If yes, for whom? To whom? Balance Due			Are you a a Co-Maker, Endorser, or Guarantor on any loan or contract? Yes No If yes, for whom? To whom? Balance Due

	I REQUEST THAT MONTHLY PAYMENTS BE DEDUCTED DIRECTLY FROM MY ACCOUNT# AT FIDELITY BANK.
Type "yes" in this box to agree to these terms.	The above information is true and complete. I/We authorize the Bank to obtain credit information about me which the bank considers necessary to evaluate this application, and authorize the Bank to disclose any credit information which relates to this application or to any credit extended by the Bank as the result of this application. I understand that the Bank will retain this application whether it is approved or not.
	Date

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