MAINSTREET BANK
301 E BROADWAY
ASHLAND MO 65010
PHONE: 573-657-0606
FAX: 573-657-0202
WWW.MSBMO.COM
BORROWER
CO-BORROWER
Name: _____________________________
Phone Number: _____________________
Cell Phone Number: __________________
Email Address: ______________________
Address: ___________________________
___________________________
# of Years: Own____ Rent ____ $_______
Previous Address if less than 2 years:
___________________________
___________________________
Name: _____________________________
Phone Number: _____________________
Cell Phone Number: __________________
Email Address: ______________________
Address: ___________________________
___________________________
# of Years: Own ____ Rent ____ $_______
Previous Address if less than 2 years:
___________________________
___________________________
Date of Birth: _______________________
Social Security Number: _______________
Date of Birth: _______________________
Social Security Number: _______________
Employer: __________________________
Employer Address: ___________________
__________________________
Phone: _____________________________
Number of years employed: ____________
Position: ___________________________
Income
Gross Monthly Income: _______________
Other Income: ______________________
Child Support Payments: ______________
Assets
Checking Location: __________________
Balance: ____________________
Savings Balance: _____________________
Retirement: ________________________
Employer: __________________________
Employer Address: ___________________
__________________________
Phone: ____________________________
Number of years employed: ___________
Position: ___________________________
Income
Gross Monthly Income: _______________
Other Income: ______________________
Child Support Payments: ______________
Assets
Checking Location: __________________
Balance: _____________________
Savings Balance: ____________________
Retirement: ________________________
Russ Marshman
NMLS: 842706
Cell: 660-815-7603
David Kruger
NMLS: 1184219
Cell: 660-631-2544
Ashley Benny
NMLS: 405493
Phone: 660-427-5201
Email: rmarshman@msbmo.com
Email: dkruger@msbmo.com
Email: abenny@msbmo.com
I/We hereby authorize Mainstreet Bank to order an in-file credit report. I/We understand this is for the internal
use of Mainstreet Bank and that I/we will not receive a copy of the report.
____________________________________________________
Signature of Prospective Borrower
Date
____________________________________________________
Signature of Prospective Co-Borrower
Date
This information is provided to assist real estate professionals and is not an advertisement to extend consumer credit as defined by section 226.2 or
Regulation Z. Interest rates and points are subject to change without notice and should be used for comparative purposes only. All figures are
estimates and vary based on final sales price.