Loan Application

Effective October 1, 2003

In accordance with section 326 of the USA Patriot Act, CUNAME HERE is required by Federal law to obtain, verify, and record information that identifies each person who opens an account or is being added as a signatory to a new or existing account. In some cases, identification will be requested for those banking with us prior to the effective date of the customer identification requirements because original documentation was not obtained with the opening of the accounts.

What this means for you:

When you open an account or are going to be added as a signatory to an account, we will ask for you name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents.

* Required Field

* Purpose of Loan

Term

Account Number

Amount Requested

This application initiates the loan process. Final signature(s) will be required to advance funds, including signatures for joint applicants. We will contact you the next business day.

PLEASE TELL US ABOUT YOURSELF (PRIMARY BORROWER)

* Full Name

* Street Address

* City

* State

* Zip

* Years There

* Home Phone

() -

* Work Phone

() - ext

* Driver's License Number

* Driver's License State

* Social Security Number

- -

* Birth Date

/ / (mm/dd/yyyy)

E-Mail Address

PLEASE TELL US ABOUT YOUR JOB (PRIMARY BORROWER)

* Current Employer

* Years There

Phone Number

() - ext

* Position

* Gross Montly Income

Note: 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

Other Income

Source

PLEASE TELL US ABOUT YOURSELF (CO-BORROWER)

Full Name

Street Address

City

State

Zip

Years There

Home Phone

() -

Work Phone

() - ext

Driver's License Number

Driver's License State

Social Security Number

- -

Birth Date

/ / (mm/dd/yyyy)

E-Mail Address

PLEASE TELL US ABOUT YOUR JOB (CO-BORROWER)

Current Employer

Years There

Phone Number

() - ext

Position

Gross Montly Income

Note: 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

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
Rent
Auto
Auto 2
Charge Card
Other
Other
Other

Amount you pay in alimony or child support

Are you a Co-Borrower on any other loans?

Yes
No

If yes, for whom

Where

Monthly Payment

AGREEMENT

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. WE UNDERSTAND THAT FEDERAL LAW REQUIRES THE VERIFICATION OF IDENTIFICATION FOR ALL NEW ACCOUNTS SHOULD I NOT HAVE AN EXISTING ACCOUNT. I/WE AUTHORIZE YOU TO OBTAIN SUCH INFORMATION AS YOU MAY REQUIRE CONCERNING THE STATEMENTS MADE IN THIS APPLICATION AND PROPER IDENTIFICATION, AND AGREE THAT THE APPLICATION SHALL REMAIN YOUR PROPERTY, AND YOU ARE AUTHORIZED TO ANSWER QUESTIONS ABOUT YOUR CREDIT EXPERIENCE WITH ME/US.

I accept the terms of the disclaimer above and submit my application.

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