VISA Application

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* Required Fields

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. Please contact us after 4:30 of the day that the application is sent or the next business day if it is after 2:00 pm Eastern time.

PLEASE TELL US ABOUT YOURSELF (PRIMARY BORROWER)

Full Name:

Street Address:

Street Address 2:

City:

State:

ZIP:

Home Phone:

Work Phone:

Driver's License Number:

Driver's License State:

Social Security Number:

Birth Date:

/ /

E-Mail Address:

PLEASE TELL US ABOUT YOUR JOB (PRIMARY BORROWER)

Current Employer:

Years There:

Phone Number:

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:

Street Address 2:

City:

State:

ZIP:

Years There:

Home Phone:

Work Phone:

Driver's License Number:

Driver's License State:

Social Security Number:

Birth Date:

E-Mail Address:

PLEASE TELL US ABOUT YOUR JOB (CO-BORROWER)

Current Employer:

Years There:

Phone Number:

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

Mortgage

Debt Payments:

Payment to:

Monthly Payment:

Balance Owed:

Rent

Debt Payments:

Payments to:

Monthly Payment:

Balance Owed:

Auto

Debt Payments:

Payment to:

Monthly Payment:

Balance Owed:

Auto 2

Debt Payments:

Payment to:

Monthly Payment:

Balance Owed:

Charge Card

Debt Payments:

Payment to:

Monthly Payment:

Balance Owed:

Other

Debt Payments:

Payment to:

Monthly Payment:

Balance Owed:

Other

Debt Payments:

Payment to:

Monthly Payment:

Balance Owed:

Other

Debt Payments:

Payment to:

Monthly Payment:

Balance Owed:

Amount you pay in alimony or child support:

Are you a Co-Borrower on any other loans?

Yes

If yes, for whom:

Where:

Monthly Payment:

Loan Application Disclosure of Terms and Conditions

I/we accept and consent to the loan application disclosure information outlined below. I/we further agree that if this application is approved and
subsequently executed,that I/we agree to a $35.00 Loan Fee, and that I/we will accept and sign an original application form with the same written
disclosure information included therein. If there is more than one applicant, clicking the checkbox is intended as a representation to the Credit
Union that all such parties consent to these terms and conditions.

Specific Loan Application Disclosure Information

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:

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

Security Code: