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Welcome to Mid Penn Bank On-Line.  This loan application is intended for current customers or those moving to our geographic area who will be banking with us. 

Our primary service area includes the following counties of Pennsylvania:  Dauphin, Cumberland, Schuylkill and Northumberland.

Our secondary service area includes portions of the following counties of Pennsylvania:  Perry, Juniata, Snyder, York, Lancaster, Lebanon and Adams County.

We are committed to providing you with the best customer service possible which is why we must limit our loan service area.  You will be required to identify yourself as a current customer or as residing in one of the above counties on the loan application for your application to be processed.  We apologize, but if you do not reside in one of these counties or if you are not a current customer, your application may be rejected based solely on the information that you do not reside within our loan service area, or that you are not a current bank customer.  If you should need further assistance with a loan, please e-mail us.

Upon receipt of your electronically submitted application, Mid Penn Bank will mail you a copy of the required disclosures within three business days of the date of receipt of your un-signed application. Upon approval of your application, you will be required to sign the loan application at one of our office locations which is convenient to you. Applicants must be 18 years of age or older to apply.


IMPORTANT INFORMATION ABOUT
PROCEDURES FOR OPENING A NEW ACCOUNT

To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify and record information that identifies each person who opens an account.

 What this means for you:

When you open an account, we will ask for your name, address, date of birth
and driver's license or other identifying documents.

INSTALLMENT LOAN HOME EQUITY LOAN
CONSTANT CREDIT LINE OF CREDIT /
OVERDRAFT PROTECTION		 HOME EQUITY LINE OF CREDIT


If you have a CODE, please enter it here

Check box for joint account.   Please check here if you are applying for a joint account or an account that you and another person will use and complete all applicable sections, including the Joint Application information.

APPLICANT INFORMATION
Last Name First Name MI
Social Security Number Are you a current customer? Yes No
   
Street Address
City State Zip
County
Telephone How long at above address?
E-mail address Birthdate
Previous address (if less than 3 years at current address)
Complete the Marital Status section ONLY if applying for joint or secured credit.
Marital Status: Married Separated
  Unmarried (includes single, divorced and widowed)
Dependents How long at this address?
Children Adults
Housing Information
   Rent
Monthly Payment:
   Live With Parents
   Own
Monthly Payment:
Balance on Mortgage:
 
Present Employer Occupation/Position
Employer's Address
Length of Employment Employer's Telephone Number
  Years   Months
Annual Gross Salary  
Other Income: DO NOT REVEAL INCOME from alimony, child support, or separate maintenance payments, unless you are relying on such income to repay this account.
Total Gross Monthly Income: Describe Source of Other Income
If employed less than three years with present employer, please complete previous employer information below.
Previous Employer Former Occupation/Position
Previous Employer's Address
Length of Employment Previous Employer's Telephone Number
Years Months
Your Bank's Name
Your Bank's Address
Balance in Checking Balance in Savings
AUTOMATIC DEDUCTION OF LOAN PAYMENT
I certify that the information stated is complete and accurate, and has been furnished by me knowing that you intend to rely on it in considering my application. I understand that you may request a consumer report in connection with this application and for purposes of updating, renewing or extending further credit, and, if I ask, I will be informed whether or not such a report was requested, and if so, the name and address of the consumer reporting agency that furnished the report. I also authorize you to check my employment history and to exchange account and credit information about me with anyone who may ask, or with anyone who may ask you.
Checking Acct. #:
Savings Acct. #:


CREDIT REFERENCES
Creditor Account Number Monthly Payment
$
$
$
$
$
$
$
PERSONAL REFERENCE (Name of Nearest Relative Not Living With You)
Last Name First name
Street Address
City State Zip
Telephone Relationship to you
Have you ever filed bankruptcy or had a judgement, lien, or legal preceding against you?
Amount of Loan Requesting
Number of Months
MPB Checking Acct. # if Applying Overdraft Protection or Line of Credit
Purpose of Loan
Collateral Being Offered to Secure Loan
COMPLETE THIS SECTION FOR AN AUTO OR MOBILE HOME LOAN
Name(s) to appear on vehicle title (title holder to sign security agreement)
Street Address
City State Zip
COMPLETE THIS SECTION FOR AN AUTO, MOBILE HOME, OR BOAT LOAN
Name of Seller/Dealership Phone Number of Dealership
Street Address
City State Zip
Serial Number
Make/Model Year
  New   
  Used
Purchase Price (-) Down Payment (=) Amount Financed
COMPLETE THIS SECTION FOR A BOAT LOAN
Length of Boat Type
Single, Inboard, Twin, I/O
Engine Make H.P. Year
Hull/Serial Number
Boat Registration/Documentation Number (Documented owner to sign Security Agreement)
COMPLETE THIS SECTION FOR A PERSONAL LOAN
Describe what Loan Will Be Used For
COMPLETE THIS SECTION FOR A HOME IMPROVEMENT OR HOME EQUITY LOAN
Street Address of Property to be Improved
City State Zip
Property Owner(s) - All Owners Must Be Present at Closing
1 
2 
Date Purchased Present Value (prior to improvements)
Describe the Improvement(s) Planned
IF CREDIT IS FOR AUTO, MOBILE HOME, BOAT OR HOME IMPROVEMENT:
Insurance Agent's Name Insurance Company's Name
Insurance Agent's Street Address
City State Zip
Insurance Agent's Phone Number Insurance Company's Phone Number
INFORMATION FOR GOVERNMENT MONITORING PURPOSES
(Information for government monitoring purposes below should ONLY be completed for home improvement, refinance and mobile home loans.)
The following information is requested by the Federal Government for certain types of loans relating to a dwelling in order to monitor Mid Penn Bank's compliance with Equal Credit Opportunity, Fair Housing and Home Mortgage Disclosure laws. You are not required to furnish the information below, but are encouraged to do so. The law provides that a lender may not discriminate neither on the basis of the information, nor on whether you choose to furnish it. If you furnish the information, please provide both ethnicity and race.  For race, you may check more than one designation.  However, if you choose not to furnish the information and you have made this application is person, under federal regulations, the Lender is required to note ethnicity, race or sex on the basis of visual observation or surname. If you do not wish to furnish the information, please check below:
Applicant
I do not wish to furnish this information
Ethnicity: Hispanic or Latino
Not Hispanic or Latino
Race/National Origin: American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Sex: Male
Female   
CERTIFICATION
   I certify that the information stated is complete and accurate, and has been furnished by me knowing that you intend to rely on it in considering my application. I understand that you may request a consumer report in connection with this application and for purposes of updating, renewing or extending further credit, and, if I ask, I will be informed whether or not such a report was requested, and if so, the name and address of the consumer reporting agency that furnished the report. I also authorize you to check my employment history and to exchange account and credit information about me with anyone who may ask, or with anyone who may ask you.

Date:

I understand that I can submit my application electronically. Should my loan request be approved, I may be required to go to an office of Mid Penn Bank to sign any necessary documents in front of a loan officer. I am interested in going to the office to sign these documents. Please have a loan officer call me to schedule an appointment at the following daytime phone number: .
CO-APPLICANT INFORMATION
Last Name First Name MI
Social Security Number
Are you a current customer?
 Yes No
Street Address
City State Zip
County
Telephone How long at above address?
E-mail address Birthdate
Previous address(if less than 3 years at current address)
Complete the Marital Status section ONLY if applying for joint or secured credit.
Marital Status: Married Separated
  Unmarried (includes single, divorced and widowed)
Dependents How long at this address?
Children Adults
Housing Information
   Rent
Monthly Payment: $
   Live With Parents
   Own
Monthly Payment: $
Balance on Mortgage:
 $
Present Employer Occupation/Position
Employer's Address
Length of Employment Employer's Telephone Number
  Years   Months
Annual Gross Salary  
Other Income: DO NOT REVEAL INCOME from alimony, child support, or separate maintenance payments, unless you are relying on such income to repay this account.
Total Gross Monthly Income: Describe Source of Other Income
Previous Employer Previous Occupation/Position
Previous Employer's Address
Length of Employment Previous Employer's Telephone Number
Years Months
Your Bank's Name
Your Bank's Address
Balance in Checking Balance in Savings
CREDIT REFERENCES
Creditor Account Number Monthly Payment
$
$
$
$
$
$
$
PERSONAL REFERENCE (Name of Nearest Relative Not Living With You)
Last Name First Name
Street Address
City State Zip
Telephone How long at above address?
Have you ever filed bankruptcy or had a judgement, lien, or legal preceding against you?
INFORMATION FOR GOVERNMENT MONITORING PURPOSES
(Information for government monitoring purposes below should ONLY be completed for home improvement, refinance and mobile home loans.)
The following information is requested by the Federal Government for certain types of loans relating to a dwelling in order to monitor Mid Penn Bank's compliance with Equal Credit Opportunity, Fair Housing and Home Mortgage Disclosure laws. You are not required to furnish the information below, but are encouraged to do so. The law provides that a lender may not discriminate neither on the basis of the information, nor on whether you choose to furnish it. If you furnish the information, please provide both ethnicity and race.  For race, you may check more than one designation.  However, if you choose not to furnish the information and you have made this application is person, under federal regulations, the Lender is required to note ethnicity, race or sex on the basis of visual observation or surname. If you do not wish to furnish the information, please check below:
Co-Applicant
I do not wish to furnish this information
Ethnicity: Hispanic or Latino
Not Hispanic or Latino
Race/National Origin: American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Sex: Male
Female   
CERTIFICATION
  I certify that the information stated is complete and accurate, and has been furnished by me knowing that you intend to rely on it in considering my application. I understand that you may request a consumer report in connection with this application and for purposes of updating, renewing or extending further credit, and, if I ask, I will be informed whether or not such a report was requested, and if so, the name and address of the consumer reporting agency that furnished the report. I also authorize you to check my employment history and to exchange account and credit information about me with anyone who may ask, or with anyone who may ask you.
Date:

I understand that I can submit my application electronically. Should my loan request be approved, I may be required to go to an office of Mid Penn Bank to sign any necessary documents in front of a loan officer. I am interested in going to the office to sign these documents. Please have a loan officer call me to schedule an appointment at the following daytime phone number: .
Print and retain this form for your records.