Dubuque Bank & Trust

Agricultural Services

Insurance

HTLF Investment Services

Dubuque Bank & Trust
You must be 18 years of age to apply for an account over the Internet. If you are under 18 years of age, please visit one of our offices or call 563-589-2000.

Type of Account

INDIVIDUAL CREDIT: Complete the applicant information below with information about your spouse in the co-application/spouse section only if you are married and a Wisconsin resident.

JOINT CREDIT WITH SPOUSE: Complete the applicant and spouse sections and both applicant and spouse must sign below.

JOINT CREDIT WITH who is not your spouse. Each of you must complete a separate application as if applying for separate credit and submit them together, including completing the co-applicant/spouse section below if you are married and a Wisconsin resident.

Account Holder Information

Borrower Name (First M. Last):

Date of Birth (mm/dd/yyyy):

Co-Borrower Name (First M. Last):

Date of Birth (mm/dd/yyyy):

Marital Status: Married

Unmarried

Separated

Address:

City, State: ,

Zip-Plus4: -

Borrower SSN:

Co-Borrower SSN:

Home Phone Number: ( ) -

Work Phone Number: ( ) -

Fax: ( ) -

Email:

History

# Acres Owned:		Rented:
Acres of Corn:		Acres of Soybeans:
Other Crops:
Description of Livestock Enterprise:

Equipment

Year:	Make:	Model:		Type:
Serial/VIN Number:
Is item financed or leased to be used for custom work?
Insurance Company for equipment/vehicle:			Phone No.

Dealer Name:

Phone No:

Address:

E-mail:

Sales Person/Contact:

Fax No:

Customer Name:

Requested Closing Date:

Loan Request

Sale Price:

Interest Rate Type: Fixed Variable

Trade In:

Quoted Interest Rate:

Down Payment:

Payment Frequency:

Monthly	Quarterly
Semi-Annual	Annual

Total Amt Financed:

First Payment Due:

Loan Term:

Lease Request

Lease Amount Requested:	New Used
Term: /Yrs.
Payment Frequency: Monthly Quarterly Semi-annual Annual

COMPLETE THIS SECTION FOR REFINANCE REQUESTS ONLY

Refinance Amount Requested: $	Current # hours on equipment:
Current Lienholder:	Account #:
Address:	Next Payment Due Date:
Phone:	Contact:
Comments:

Provide a complete equipment description including make, model, serial #, sales price, and date.

Contact Information

Time Available for Contact:
	A.M.	P.M.
Contact At:	Home	Work

Taxpayer Identification Number Certification

Social Security Number(s): The Social Security Number(s) shown above is my correct SSN.

Backup Withholding: I am not subject to backup withholding either because I have not been notified that I am subject to backup withholding as a result of a failure to report all interest or dividends, or the Internal Revenue Service has notified me that I am no longer subject to backup withholding.

Exempt Recipients: I am an exempt recipient under the Internal Revenue Service Regulations.

Nonresident Alien: I am not a United States person, or if I am an individual, I am neither a citizen nor a resident of the United States.

I certify under penalties of perjury the statements checked in this section are true.

I authorize the bank to obtain a copy of my current credit report as a condition of acceptance of this application and for the purpose of extension of or renewal of credit.

I would like to access this account through Online Banking.

Required federal disclosures will be provided to you at the time of actual account opening.

Comments:


	© 2006 Dubuque Bank & Trust. All rights reserved. Privacy \| Service Fees