| Loan Information: | ||||||
| Amount requested: | Term: | |||||
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Co-applicant:  Yes No |
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| Primary Applicant: | |
| Last Name: | First Name, M.I.: |
| Social Security #: | Date of Birth mm/dd/yyyy: |
| Credit Union Acct No.: | |
| Street Address: | |
| City: | State, ZIP: |
| How long (yrs): | Home Phone: |
| County: | |
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| Previous Address, if less than 2 years: | |
| How long (yrs): | # of Dependents: |
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| Present Employer: | |
| Address (street, city, state, zip): | |
| Work Phone: | Job Start Date: |
| Position: | Salary (gross monthly): |
| Other Income (amount): | |
| Source: 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. |
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| Previous Employer: | |
| Address (street, city, state, zip): | |
| How long (yrs): | Position: |
| Salary (gross monthly): | |
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| Checking Account with: | Savings Account with: |
| Had credit in another name?: Yes No |
Any Judgements?: Yes No |
| Filed Bankruptcy?: Yes No When (month/year): |
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| Repossession or Foreclosure?: Yes No When (month/year): |
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| Driver's License Number: | |
| Joint Applicant: If you are relying on spouse's income as a basis for payment complete the following. | |
| Last Name: | First Name, M.I.: |
| Social Security #: | Date of Birth mm/dd/yyyy: |
| Street Address: | |
| City: | State, ZIP: |
| Home Phone: | |
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| Present Employer: | |
| Address (street, city, state, zip): | |
| Work Phone: | Job Start Date: |
| Position: | Salary (gross monthly): |
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| Previous Employer: | How long: |
| References: | |
| References (nearest relative): | |
| Address (street, city, state, zip): | |
| Phone Number: | Relation: |
| Insurance Company and Agent: | |
| Indebtedness/Liabilities: | ||||
| Mortgage or Rent with: | Address: | Balance Owing: | Mo. Payment: | Market Value: | Auto Loan: | Account No.: | Balance Owing: | Mo. Payment: | Year/Make: |
| Credit Union: | Address/Account No.: | Balance Owing: | Mo. Payment: | Comment: |
| Credit Union: | Address/Account No.: | Balance Owing: | Mo. Payment: | Comment: |
| Credit Union: | Address/Account No.: | Balance Owing: | Mo. Payment: | Comment: |
| Credit Union: | Address/Account No.: | Balance Owing: | Mo. Payment: | Comment: |
| Other: | Address/Account No.: | Balance Owing: | Mo. Payment: | Comment: |
| Other: | Address/Account No.: | Balance Owing: | Mo. Payment: | Comment: |
| Other: | Address/Account No.: | Balance Owing: | Mo. Payment: | Comment: |
| Child support, Alimony or Separate maintenance : |
To Whom: | Mo. Payment: | Comment: | |
| Co-Signer, where: For Whom: |
Address/Account No.: | Balance Owing: | Mo. Payment: | Comment: |
| Note: | |
| Income verification is required; other information may be required. I certify that statements on this application are true and complete. I authorize any person, association, firm or corporation to furnish, on request of this Financial Institution, information concerning me or my affairs.(Sec. 1014, Title 18, U.S. Code makes it a Federal Crime to knowingly make a false statement on this application.) |
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| Primary Signature: | Date: |