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Confidential Questionnaire Use this form to submit your information. We will respond to you as soon as possible. First Name Middle Last Name Address City State Zip County Population Business Phone Home Phone Fax Cell Email address Spouse's Name Spouse's Occupation Home Town Spouse's Home Town Children: Ages/Names Employment History Your Title Management Operations Trust Lending   Current Employer (Bank, S&L, Financial Institution) Address City State Zip Assets $ Loans $ ROA Location Parent Company Location Assets $ Beginning Date of Employment Ending Date Titles Rank in bank or department Number you supervise Years in Banking List your top three primary duties and responsibilities: 1 2 3 If your position includes lending: Size of Bank's loan portfolio $ MM Size of your personal loan portfolio $ MM Breakdown: Personal Commercial $ Personal Commercial Real Estate $ Personal Residential Real Estate $ Personal Consumer $ Personal Agricultural $ Size of your Typical Personal Loan $ Largest Personal Loan $ Give examples of your personal loans (Ex. Hotel $500,000, Two Family Dwelling $200,000, Ag Operating Line $100,000, Inventory $50,000) Describe your experience with the following: SBA, FmHA, Credit Review, Credit Analysis, Documentation, Financial Statement Analysis, Appraisals, Supervisory role, Business Development, Sales Training Current Salary and Benefits Salary $ Car Medical insurance 401K ESOP Disability insurance Vacation weeks Bonus Incentives Pension $ Life insurance $ Education Colleges Attended, Dates, Degrees Banking schools, job related courses and seminars (show location and dates). Prior Employment (list in Chronological Order) Name of Firms, Location, Asset Size, Dates of Employment, Titles Held, Duties, Accomplishments Civic Involvement List civic organizations, offices held, campaigns, honors, awards, church activities, military Before submitting the completed form, we suggest that you print this out in the event that there are network difficulties. This will save your information. If for some reason this does not transmit, please mail the completed form to our address on the home page.

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Date Last Modified: 4/23/07