Purpose of Loan

Purpose of Loan: Term:

Account Number:		If new customer enter 101
Amount Requested
This application initiates the loan process. Final signature(s) will be required to advance funds.
PLEASE TELL US ABOUT YOURSELF (PRIMARY BORROWER)
Full Name
Street Address
City, State Zip
Years There
Home Phone
Work Phone
Driver's License State/Number:
Social Security Number
Birth Date
E-Mail Address
PLEASE TELL US ABOUT YOUR JOB (PRIMARY BORROWER)
Current Employer
Years There
Phone Number
Position
Gross Monthly Income
alimony, child support, or separate maintenance income need not be revealed if you do not wish to have it considered as basis for repaying this obligation.
Other Income
Source
The following information pertains to CO-BORROWER. If there is not a CO-BORROWER, then scroll down to the green section.
PLEASE TELL US ABOUT YOURSELF (CO-BORROWER)
Full Name
Home Address
City, State Zip
Years There
Home Phone
Social Security Number
Birth Date
PLEASE TELL US ABOUT YOUR JOB (CO-BORROWER)
Current Employer
Years There
Phone Number
Position
Gross Monthly Income
Other Income
Source
PLEASE LIST NEAREST RELATIVE NOT LIVING WITH YOU
Full Name
Home Address
City, State Zip
Phone Number
IF APPLYING FOR A PERSONAL UNSECURED LOAN SUCH AS VACATION OR OTHER PLEASE SELECT A FORM OF COLLATERAL
Collateral:
MONTHLY PAYMENTS
Debt Payments	Payment to	Monthly Payment	Balance Owed
Mortgage or Rent
Auto:
Charge Card:



$ Amount you pay in alimony or child support
alimony, child support, or separate maintenance income need not be revealed if you do not wish to have it considered as basis for repaying this obligation.
Are you a Co-Borrower on any other loans?		Yes No
For Whom:	Where:		Monthly Payment:

Click the "I accept the terms of the disclaimer above and submit my application" button to send the application to us via the WWW after reading the disclaimer below. By clicking "I accept the terms of the disclaimer above and submit my application", you accept the terms of the disclaimer below.

DISCLAIMER: I/WE HEREBY CERTIFY THAT ALL STATEMENTS MADE ARE TRUE AND COMPLETE, ARE SUBMITTED FOR THE PURPOSE OF OBTAINING CREDIT, AND THAT THE CREDIT UNION MAY RELY ON THEM FOR SUCH DETERMINATION. I/WE AUTHORIZE YOU TO OBTAIN SUCH INFORMATION AS YOU MAY REQUIRE CONCERNING THE STATEMENTS MADE IN THIS APPLICATION, AND AGREE THAT THE APPLICATION SHALL REMAIN YOUR PROPERTY, AND YOU ARE AUTHORIZED TO ANSWER QUESTIONS ABOUT YOUR CREDIT EXPERIENCE WITH ME/US.

Signature: _________________________________Date: _______________________