Member FDIC   |   Equal Housing Lender

Quick Loan Request Form - FSB Canby
Submitter Information (Required)
First Name
Last Name
Resolve the errors marked in red before submitting again.

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Complete this form on-line and click "Submit". Upon receipt we will send you the proper disclosures. We will also contact you to discuss your loan request within three business days. To safeguard your privacy, please QUIT your browser and restart it again after submitting this form. Our Loan Request Form is for personal loans and is NOT intended for Business use.

$ Amount Applying For

No. of Months

Purpose of Loan
Is this residence your:
Details of Transaction Purchase Price $
Borrower's NameSocial Security No.

Contact Phone Date of Birth

Present Address
No. Yrs.
Name & Address of Employer
Co-Borrower's NameSocial Security No.

Contact PhoneDate of Birth

Co-Borrower Present Address
No. Yrs.
Name & Address of Employer
Gross Monthly Income
Borrower $Co - Borrower $Total $

Acknowledgement and Agreement

Each of the undersigned specifically represents to Lender and to Lender's actual or potential agents, brokers, processors, attorneys, insurers, servicers, successors and assigns and agrees and acknowledges that:

(1) the information provided in this form is true and correct as of the date set forth opposite my signature and that any intentional or negligent misrepresentation of this information contained in this form may result in civil liability, including monetary damages, to any person who may suffer any loss due to reliance upon any misrepresentation that I have made on this form, and/or in criminal penalties including, but not limited to, fine or imprisonment or both under the provisions of Title 18, United States Code, Sec. 1001, et seq.;

(2) the loan requested pursuant to this form (the "Loan") will be secured by the collateral described herein;

(3) the collateral will not be used for any illegal or prohibited purpose or use;

(4) all statements made in this form are made for the purpose of obtaining a loan;

(5) any owner or servicer of the Loan may verify or reverify any information contained in the form from any source named in this form, and Lender, its successors or assigns may retain the original and/or an electronic record of this form, even if the Loan is not approved;

(6) the Lender and its agents, brokers, insurers, servicers, successors and assigns may continuously rely on the information contained in the form, and I am obligated to amend and/or supplement the information provided in this form if any of the material facts that I have represented herein should change prior to closing of the Loan;

(7) in the event that my payments on the Loan become delinquent, the owner or servicer of the Loan may, in addition to any other rights and remedies that it may have relating to such delinquency, report my name and account information to one or more consumer credit reporting agencies;

(8) ownership of the Loan and/or administration of the Loan account may be transferred with such notice as may be required by law;

(9) neither Lender nor its agents, brokers, insurers, servicers, successors or assigns has made any representation or warranty, express or implied, to me regarding the collateral or the condition or value of the collateral; and

(10) my transmission of this form as an "electronic record" containing my "electronic signature," as those terms are defined in applicable federal and/or state laws (excluding audio and video recordings), or my facsimile transmission of this form containing a facsimile of my signature, shall be as effective, enforceable and valid as if a paper version of this form were delivered containing my original written signature.

To be completed and submitted by Borrowers
Borrower's NameDate

Co-Borrower's NameDate