Loan Application

* - Indicates required fields

Are you applying as an individual or with a co-applicant? * Individual Joint

Term Requested (months) *

Will the loan proceeds be used towards a hemp related business or product? * Yes No

This includes but is not limited to: general retail sales of CDB Oil, Dispensary Sales of CBD oil, Pharmacy Sale of CBD oil, Online sales of CBD oil and Hemp producers of fibers, textiles, seed, meal, oil, imports or exports.

Will the loan proceeds be used towards a marijuana related business or product? * Yes No

This includes but is not limited to: adult or medical use, retail, processing, cultivation, testing, operations that support marijuana businesses, landlords of a marijuana business, etc.

Social Security Number *

Mother's Maiden Name *

Number of Dependants *

Ages of Dependants *

Primary Phone Number *

Secondary Phone Number

Mailing address is different than street address.

Is your present address your permanent address? * Yes No

How long have you been at your present address? * Less than 1 year 1 - 2 year(s) 3-5 years 5+ years

Marital Status * Married Separated Unmarried (including single, divorced, or widowed)

Nearest Relative Not Living With You *

Relationship (of Relative) *

Phone Number (of Relative) *

Address (of Relative) *

City (of Relative) *

State (of Relative) *

Zip Code (of Relative) *

Employment/Income Information of Primary Applicant

Name of Current Employer *

Gross Annual Salary *

Occupation/Position *

How long with present employer? *

Sources of Other Income

Amount of Other Income

NOTICE: Alimony, Child Support, or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying the obligation.

Is your alimony, child support, or separate maintenance income received under Court Order Written Agreement Oral Understanding Not Applicable

Active Duty * I am a regular or reserve member of the Air Force, Army, Coast Guard, Marine Corps, Navy, or Space Force on active duty or a dependent of a member of the Armed Forces on active duty (a dependent is the member's spouse, member's child under 18 years of age, or an individual for whom the member provides over half their financial support for 180 days immediately preceding today's date.) I AM NOT a regular or reserve member of the Air Force, Army, Coast Guard, Marine Corps, Navy, or Space Force on active duty.

Do you own any assets? * Yes No

Do you have any outstanding debt? * Yes No

Do you have any housing debt (Rent or Mortgage)? * Yes No

Landlord / Mortgage Holder *

Rent or Mortgage Payment * Rent Mortgage

Name in which account is carried *

Additional Information

My Auto Insurance Agent is: (Name and Address) *

I have additional questions or requests * Yes No

Acknowledgement * I am aware that I may be required to provide a copy of my Photo ID and social security card before loan processing.

We will contact you upon receiving your application to schedule a time that is convenient to finish loan processing procedures.

Which branch would you like to come into for your loan interview? * Bowman Scranton Hettinger Regent

The purpose of this questionnaire is to begin the application process. All applications are subject to approval and will be contacted to schedule a time that is convenient to finish loan procedures.

I certify that everything I have stated in this application is correct to the best of my knowledge. I understand that you will retain this application whether or not it is approved. By signing below, I authorize you to check my credit and employment history and to answer any questions about your credit experience with me.

By entering my name below, I hereby give the electronic equivalent of my signature.