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	Secured Loan An * indicates a required field. Secured Loan We value the security of your personal information. Be assured that the information you are sharing with us is protected using data encryption. General Loan Thank you for choosing your credit union for your lending needs. To begin your loan request, complete the information below. Married Applicants:  May apply for a separate account. Individual Credit means only one borrower is responsible for repaying this loan unless another person has agreed to guarantee or co-sign the loan. Joint Credit means more than one person (a borrower and co-borrower(s)) is responsible for repaying the loan. *Loan Type Choose Individual Joint *Loan Amount    *Purpose of Loan  *Payment Frequency  Annually Bi-Monthly Bi-Weekly Monthly Quarterly Semi-Monthly Weekly   Collateral Primary Collateral?  No Yes Is this a purchase?  No Yes Model Year Make Model   General Member Complete the information below. Click "Add Applicant" to enter additional applicant information, which will appear either below or on a subsequent page. You can delete an applicant by clicking "Remove Applicant".   Payment Protection Preserve your financial future. Payment protection coverages provide a valuable safety net by making loan payments in the event of disability or death of a covered member. Your election of the coverages offered below is only a statement of intent. Payment Protection options and enrollment will be finalized with your credit union. Click here to Get a Quote now or indicate your interest below.  * Yes - Provide Term Life and Disability Coverage. Yes - Provide Disability Coverage only. Yes - Provide Term Life only. No - Not at this time.   *Role  Borrower *Please check here to indicate your intent to be obligated for this loan as a borrower.   Title Prefix Dr. Miss Mr. Mrs. Ms. None * First Name  Middle Name *Last Name  Name Suffix Esq. I II III IV Jr. M.D. None Ph.D Sr. *Date of Birth   ex. mm/dd/yyyy Provide your marital status only if this loan request is for secured credit or if you reside in one of the following community property states: AZ, CA, ID, LA, NM, NV, TX, WA, WI. If neither of the preceding conditions apply, select No Answer to Marital Status. *Marital Status Choose Married No Answer Separated Unmarried *Social Security Number   ex. 999-99-9999 Preferred Contact Method Day Fax Day Phone Email Evening Fax Evening Phone Daytime Phone Number  ex. 999-999-9999 Evening Phone Number  ex. 999-999-9999 Daytime Fax Number  ex. 999-999-9999 Evening Fax  ex. 999-999-9999 E-mail address Add Applicant      Current Address *Street Number/Name/Type  **City *State  Choose Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ----------------------------- Armed Forces - America Armed Forces - Europe Armed Forces - Pacific ----------------------------- American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico Virgin Islands ----------------------------- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon *ZIP   ex. 99999-9999 or 99999 or A9A 9A9 Rent/Own? Live with Parents Other Own Rent Monthly Housing Expense   Date Moved In  ex. mm/dd/yyyy You must provide information about your spouse if any of these situations apply: 1. Your spouse is a co-borrower 2. Your spouse will use the account 3. You are relying on your spouse’s income to repay the credit 4. If the credit will be secured by property located in a community property state (AZ, CA, ID, LA, NM, NV, TX, WA, WI) Use the "Add Applicant" button to provide your spouse information.   Previous Address Complete this section only if you have not been at your current address for more than 2 years. Click "Add Previous Address" to enter additional previous address information. Street Name/Number/Type City State Choose Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ----------------------------- Armed Forces - America Armed Forces - Europe Armed Forces - Pacific ----------------------------- American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico Virgin Islands ----------------------------- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ZIP  ex. 99999-9999 or 99999 or A9A 9A9 Date Moved In  ex. mm/dd/yyyy Add Previous Address   Dependents Complete the information below. Click "Add Dependents" to enter additional dependent information. Dependent Age(s) Add Dependents   Employment Name of Employer Street Number/Name/Type Employer City Employer State Choose Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ----------------------------- Armed Forces - America Armed Forces - Europe Armed Forces - Pacific ----------------------------- American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico Virgin Islands ----------------------------- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Employer ZIP  ex. 99999-9999 or 99999 or A9A 9A9 *Years At This Job    *Gross Monthly Salary    *Pay Frequency  Annually Bi-Weekly Hourly Monthly Semi-Monthly Weekly Gross or Net Salary Gross Net   Previous Employment Complete this section only if you have worked less than 2 years at your current employer. Click "Add Previous Employment" to enter additional previous employment information. Name of Employer Street Number/Name/Type Employer City Employer State Choose Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ----------------------------- Armed Forces - America Armed Forces - Europe Armed Forces - Pacific ----------------------------- American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico Virgin Islands ----------------------------- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Employer ZIP  ex. 99999-9999 or 99999 or A9A 9A9 Years At This Job   + Add Previous Employment   Additional Income Notice: Alimony, child support, or separate maintenance income need not be revealed if you do not choose to have it considered. Additional Income Additional Gross Income - Frequency Annually Bi-Weekly Hourly Monthly Semi-Monthly Weekly Add Additional Income   Assets Provide your asset information below. Click "Add Assets" to enter information for each additional asset. Credit Union or Bank Name Amount Checking/Savings/MMI/IRA/Stocks/Bonds Checking Investment Other Retirement Savings + Add Assets   Liabilities Provide your liability information below. Click "Add Liabilities" to enter information for each additional liability. Creditor(s) Total Combined Monthly Payment   Add Liabilities   References Provide at least two references. Click "Add References" to enter information for each additional reference. Relationship to Member Creditor Friend Relative Reference Name Street Number/Name/Type Reference Address City Reference Address State Choose Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ----------------------------- Armed Forces - America Armed Forces - Europe Armed Forces - Pacific ----------------------------- American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico Virgin Islands ----------------------------- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Reference Address ZIP  ex. 99999-9999 or 99999 or A9A 9A9 Reference Day Phone  ex. 999-999-9999 Add References   Questions Do you have any outstanding judgments?  No Yes Have you ever filed for bankruptcy or had a debt adjustment plan confirmed under Chapter 13?  No Yes Have you had property foreclosed upon or repossessed in the last 7 years?  No Yes Are you a party in a lawsuit?  No Yes Are you other than a U.S. Citizen or permanent resident alien?  No Yes Is your income likely to decline in the next two years?  No Yes Are you a co-maker, co-signer or guarantor on any loan not listed above?  No Yes For whom? (Name of others Obligated on Loan) To whom? (Name of creditor) Review Your Application Review all your answers carefully. After verifying that all your information is correct, click Submit at the bottom of the page to complete your application. NOTICE TO WISCONSIN RESIDENTS: No provision of any marital property agreement, unilateral statement under S.766.59, or court decree under S.766.70 will adversely affect the rights of the credit union unless the credit union is furnished a copy of the agreement, statement or decree, or has actual knowledge of its terms, before the credit is granted or the account is opened. OHIO RESIDENTS ONLY: The Ohio laws against discrimination require that all creditors make credit equally available to all creditworthy customers, and that credit reporting agencies maintain separate credit histories on each individual upon request. The Ohio Civil Rights Commission administers compliance with this law. By submitting this application, you authorize the Credit Union to obtain credit reports in connection with this application for credit and for any update, increase, renewal, extension, or collection of the credit received. You understand that the Credit Union will rely on the information in this application and your credit report to make its decision. If you request, the Credit Union will tell you the name and address of any credit bureau from which it received a credit report on you. It is a federal crime to willfully and deliberately provide incomplete or incorrect information on loan applications made to federal credit unions or state chartered credit unions insured by NCUA.

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