Loan Type ________________ Loan Amount Requested _________________ How long do you want to finance the loan? ______________________________ How do you want to repay the loan? ______________________________ Do you want to insure this loan with optional credit insurance? (Insurance option applies to open end loans only.) Yes Single Credit Disability at 29 cents per $100.00 of loan balance per month. Yes Single Credit Life at 6 cents per $100.00 of loan balance per month. Yes Joint Credit Life at 9.6cents per $100.00 of loan balance per month. No Applicant Information Last ______________________ First ______________________ MI ___ Street _________________________________________  Birthdate  _________________ City _________________________________________   Home _________________  State ___        Zip _____________   Work _________________  Social Security Number _______________ Account Number _______________ Time at Residence_________________      Buying/Own Rent Other Employment Information (Applicant) Employer _________________        Position _________________      Length of Employment_________________      Employer Address Street_______________________________________    City________________________________________    State___        Zip _____________   Employer Phone_________________ Gross Salary _________________      Other Gross Monthly Income _________________      Source of Other Income_________________      Pay Frequency         Weekly Semi-monthly Bi-weekly Monthly 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. Alimony, child support, separate maintenance received under: court order written agreement oral understanding Co-Applicant Information Last ______________________ First ______________________ MI ___ Street _________________________________________  Birthdate  _________________ City _________________________________________   Home _________________  State ___        Zip _____________   Work _________________  Social Security Number _______________   Time at Residence_________________      Buying/Own Rent Other      Monthly Payment _________________  Employment Information (Co-Applicant) Employer _________________        Position _________________      Length of Employment_________________      Employer Address Street_______________________________________    City________________________________________    State___        Zip _____________   Employer Phone_________________ Gross Salary _________________      Other Gross Monthly Income _________________      Source of Other Income_________________      Pay Frequency         Weekly Semi-monthly Bi-weekly Monthly You promise that everything you have stated in this application is correct to the best of you knowledge. If there are any important changes, you will notify us in writing immediately. You authorize the credit union to obtain credit reports in connection with this application for credit and any update, renewal or extension 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. _______________________________ __________________ Signature Date You Must Print, Sign, and Return to Credit Union (in person or by mail) A signature is needed to complete the process

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