Bank of Essex Credit Application
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It is the mission of Bank of Essex to serve residents in and around the Virginia counties in which our branches are located. We reserve the right to refuse applications from non-customers outside our market area.

Read the Bank of Essex Privacy Policy before you begin.

Questions about our lending policy, lending area or about this application: Contact Us!
Credit Request Information
Type of Credit Requested :

Applications for loans secured by residence or dwelling or for purposes of home improvement, whether secured or unsecured, are not accepted over the Internet. Please visit or call one of our convenient locations. 		Secured
Unsecured
Individual Credit
(relying solely on my income or assets)
Individual Credit
(relying on my income or assets as well as
income or assets from other sources)
Joint Credit
Amount / Credit Limit Requested :
For How Long :
Want to Repay : Monthly
Payment Date Desired :
Proceeds of Loan to be Used For :

Section A - Individual Applicant Information
Last Name : First : Middle :
Birthdate :
Email Address (optional):
Telephone Number :
Driver's License Number :
Social Security Number :
Number of Dependents : Ages of Dependents :
Mailing Address :
Street Address :
City : State : Zip :
County : Do you : Own Rent How Long :
Permanent Resident of U.S. : Yes No
Previous Address (if less than 3 yrs. at present address):
City : State : Zip :
County : Did you : Own Rent How Long :
Have you ever had merchandise repossessed? Yes No
Employer (Company Name & Address) :
If Self-employed, Name and Nature of Business :
Length of Employment :
Business Phone (Ext.) :
Position or Title :
Salary Per Month : Gross $ Net $
Complete only if employed less than 2 years at current job -
Previous Employer (Company Name & Address) :
Length of Employment :
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 this obligation.
Alimony, child support, or separate maintenance received under :
Court Order Written Agreement Oral Agreement
Sources of Other Income :
Amount Per Month :
Is any income listed in this section likely to be reduced before the credit request is paid off?
If so, please explain. No Yes
Have you previously received credit from us? No Yes If so, when?
Name & Address of Nearest Relative Not Living with You :
Relationship :
Telephone :

Section B - Joint Applicant or Other Party Information
Complete only if: for joint credit or for individual credit relying on income or assets of another person.
Last Name : First : Middle :
Birthdate :
Telephone Number :
Driver's License Number :
Social Security Number :
Number of Dependents : Ages of Dependents :
Relationship to Applicant (if any) :
Mailing Address :
Street Address :
City : State : Zip :
How Long :
Permanent Resident of U.S. : Yes No
Have you ever had merchandise repossessed? Yes No
Employer (Company Name & Address) :
If Self-employed, Name and Nature of Business :
Length of Employment :
Business Phone (Ext.) :
Position or Title :
Salary Per Month : Gross $ Net $
Previous Employer (Company Name & Address) :
Length of Employment :
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 this obligation.
Alimony, child support, or separate maintenance received under :
Court Order Written Agreement Oral Agreement
Sources of Other Income :
Amount Per Month :
Is any income listed in this section likely to be reduced before the credit request is paid off?
If so, please explain. No Yes
Has Joint Applicant or Other Party ever received credit from us? No Yes
If so, when?

Section C - Asset and Debt Information
If Section B has been completed, this Section should be completed giving information about both the Applicant and Joint Applicant or Other Person. Please mark Applicant related information with an "A", Joint Applicant related information with a "J", and Other with an "O". If Section B was not completed, only give information about the Applicant in this Section.
Assets Owned
Description of Assets Account in Whose Name? Applicant Joint or Other Subject to Debt? Value
Checking Account Number(s) and Where:
$
$
Savings Account Number(s) and Where:
$
$
Certificate of Deposit(s):
$
$
Marketable Securities (issuer, type, number of shares):
$
$
Real Estate (location, date acquired):
Property Type : Single Family Duplex Triplex 4-plex
Condominium Under Development Land Other
$
Property Type : Single Family Duplex Triplex 4-plex
Condominium Under Development Land Other
$
Life Insurance (issuer, face value):
$
$
Automobiles (make, model, year):
$
$
Other (list):
$
$
Total Assets : $
Outstanding Debts
(include charge accounts, installment contracts, credit cards, rent, mortgages, and other obligations)
Creditor Account Number In Whose Name? Original Balance Current Balance Monthly Payments
Landlord or Mortgage Holder:
Rent
Mortgage 		$ $ $
Automobiles (describe):
$ $ $
$ $ $
Other (For Obligation Type, specify Installment, Revolving, Third-party [as Co-maker or Guarantor], or Other in the first box):
$ $ $
$ $ $
$ $ $
$ $ $
$ $ $
Total Debts : $
Complete the following information about both the Applicant and Joint Applicant or Other Person (if applicable) :
Are you obligated to make Alimony, Support or Maintenance Payments? Yes No
If yes, to (Name & Address) :
Amount per Month : $
Are you a co-maker, endorser, or guarantor on any loan or contract? Yes No
If yes, for whom? :
To whom? :
Are there any unsatisfied judgements against you? Yes No
If yes, to whom owed? :
Amount : $
Have you ever been declared bankrupt? Yes No
If yes, where? :
Year :

Section D - Secured Credit
Complete only if credit is to be secured. Briefly describe the property to be given as security:
Property Description
Names & Addresses of All Co-Owners of the Property

Verification and Authorization
I certify that everything I have stated in this application and on any attachments is correct.
I authorize you to check my credit and employment history and to answer questions others may ask you about my credit record with you.
I understand that I must update credit information if my financial condition changes or upon your request.
I have read the Bank of Essex Privacy Policy and agree.
I have read the Bank of Essex Insurance Sales Disclosure and agree.


Before you submit this application, print a copy for your records.

To the applicant:
Please mail or fax any information which you are not able to fit in the space provided to:
Kevin P. Dolan
Bank of Essex
Post Office Box 965
Tappahannock, Virginia 22560

FAX: (804) 443-0148
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