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First Bank Kansas
Loan Request Form

Disclaimer: The Quick Loan Request form is not to be considered a completed application for ANY loan types. A completed application will be required after contact has been made. Expect contact time to be within 1-3 business days. NMLS# 528128.


$ Amount Applying For
No. of Months
Collateral (Home, Land, Auto, Unsecured, etc.)
Purpose of Loan

Home:

Purchase Refinance Construction Line of Credit Home ImprovementOther (explain) Is this residence your: Primary Secondary Investment

Consumer:
Auto Recreational Unsecured Land
Other (explain)
Commercial:
Vehicle Equipment Real Estate Operating Line Agriculture
Other (explain)

What bank do you currently use for your primary checking account?
Purchase Price
(if applicable)

$


Borrower's Name Social Security No.

Date of Birth

Contact Phone

Email

Present Address (Street, city, State, ZIP)
Own Rent No. Yrs.
Name & Address of Employer Self Employed

Co-Borrower's Name Social Security No.

Date of Birth

Contact Phone

Email

Present Address (Street, State, ZIP)
Own Rent No. Yrs.
Name & Address of Employer Self Employed

Gross Monthly IncomeBorrowerCo-BorrowerTotal

$ $ $
Acknowledgement and Agreement

To be completed and submitted by Borrowers

Everything that I have stated in this request form is correct to the best of my knowledge. I understand that you will retain this information in addition to the full application once it is completed. You are authorized to check my credit and employment history and answer questions about your credit experience with me.

Borrower's Name
Date
Co-Borrower's Name
Date