Name
Date
Purpose of loan
Amount Requesting

Current Loan Balance
Loan to be repaid in months or at $ per pay/month
Would  you like your loan payments deducted from your paycheck?  yes      no

Group Credit Insurance
Group credit insurance is voluntary and not a requirement of your loan.
To be eligible for Group Credit Life and/or Disability insurance, your loan must mature before your 70th
birthday. Additionally, to be eligible for Credit Disability Insurance, you must be actively at work and
gainfully employed at least 20 hours per week. As part of the enrollment process, you may be asked to
satisfactorily complete a separate Statement of insurability.

Assuming your application for credit is approved and you are eligible for insurance, the Credit Union
will disclose its total cost to you. You will also be asked to sign the request for coverage contained on
the personal loan plan note, security agreement and Truth-In-Lending Disclosure form.

Indicate which credit insurance option(s) you desire:
Joint Credit Life Insurance   Single Credit Life Insurance  
Single Credit Disability Insurance   No Insurance


Address, if RD# provide brief description of location:
Home Phone #
Work Phone #
Spouse
Number of Dependents

Your Employer
Employer's address
Occupation
Department
Length of Employment

Income
per
# of hours worked per week

Other income
per
Source

*** PROOF OF INCOME MUST ACCOMPANY THIS APPLICATION***
Nearest relative not living with you?
Relationship
Their address 

Previous address (if less than 2 years at current address)

Previous address (if at current employer less than 3 years)
Years there
Reason for leaving

Please fill out this application in detail to decrease processing time.  Everything that I have stated in
this application and credit history is correct to the best of my knowledge.  As required, my shares may
be used as security for my loan.  You are authorized to check my credit history and to answer any
questions about your credit experience with me. 

Do you agree with these conditions? yes      no
If requesting joint credit:
Spouse Name
Credit History
  Creditor Present Balance Monthly Pmt. Up to Date
Rent/Mortgage
Auto Loan
Auto Loan
Bank Loan
Bank Loan
Fin. Company
Fin. Company
Visa
Visa
Master card
Master card
Lowe's
Boscov's
Discover
Sears
J.C. Penney's
PHEAA
Other
Other
Are you a co-maker, co-signer or guarantor on any loans? yes      no
If yes, please provide debtors' current loan balance, and other details
(including name and address of any creditors):

Are there any unsatisfied judgments, garnishments,
or lawsuits pending against you?		 yes      no
If yes, please provide date and place of filing:

Have you been granted credit in another name? yes      no
If yes, what was that name and where was the credit granted:

Are you presenting liable for any alimony, child support, or separate maintenance payments? yes      no
If yes, what is the amount and frequency of those payments:

Do you have any other loan or credit application in the last six months? yes      no

Have you declared bankruptcy in the last 14 years? yes     no


Representations & Authorizations
You represent everything stated in this application is correct to the best of your knowledge. You
further represent you have provided a complete listing of all your debts and obligations. You
authorize the Credit Union to investigate your credit record, verify your employment and income
information, and answer questions regarding your credit history. You also authorize the Credit
Union to obtain credit reports in connection with this application and for any update, renewal or
extension of the credit received. If you request it, 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 the National Credit Union Administration.

__________________________ _______________
Applicant Signature Date
__________________________ _______________
Witness(if requested) Date

Credit Union Use Only
Loan Officer
Approved Counter-Offer to be made. Application approved if applicant accepts all conditions set forth below. __________________________ __________
Denied Referred to Credit Committee Loan Officer Signature Date

Credit Committee
Approved Counter-Offer to be made. Application approved if applicant accepts all conditions set forth below.    
Denied     __________________________ __________
      Committee Member Signature Date
      __________________________ __________
      Committee Member Signature Date
      __________________________ __________
      Committee Member Signature Date