Amount
Requested
$_____________ |
To Be Repaid In (estimated)
_____________months |
Requested
Periodic Payment
$_____________ |
Purpose/Collateral:
_________ __________ |
|
|
| |
MARRIED
APPLICANTS may apply for a a separate account. A Credit
Union may only extend direct credit to menber. A joint
applicant for credit will be considered a guarantor
or co-signer if such person is not a credit union member.
Check the type of credit account you wish
to apply for.
|
Individual Credit - You must
complete the application section about yourself
and the other section about your spouse if:
You live in a coummunity property state (AK,
AZ, CA, ID, LA, NM, NV, P.R., TX, WA, WI) or
your spouse will use the account, or you are
relying on your spouse's income as a source
of repayment. |
|
Joint
Credit - If you are applying for a joint
account or an account that you and another person
will use, you must complete the application and
other section. |
If you intend to apply for joint credit, you understand
that the Credit Union may need to document any non-member
as a guarantor/co-signer as explained above.
| X |
__________________________________________ |
X |
__________________________________________ |
| |
Applicants
Signature Date |
|
Co-Applicant
Signature Date |
|
| INFORMATION
ABOUT PROTECTION FOR YOUR LOANS |
|
| Group
Credit Insurance is available on loans made to
Credit Union members. Insurance is voluntary and
not required to obtain credit. If you would like
information about Group Credit Insurance, check
below.If you answer "yes", then the
credit union will disclose the cost of this voluntary
payment protection to you. A separate election
which discloses the terms and conditions must
be signed for protection to be effective. |
| |
YES |
| Single
Credit Life Insurance |
Age |
| ____ |
|
|
YES |
| Joint
Credit Life Insurance |
Age |
| ____ |
|
|
YES |
| Credit
Disability Insurance |
Age |
| ____ |
|
| |
NO |
|
NO |
|
NO |
|
| The
Credit Union will disclose the cost of this Voluntary
Insurance to you if you checked Yes. A separate
election disclosing the terms and conditions of
the Credit Insurance must be signed for the coverage
to be effective. If you have attained or are over
the ages indicated, you are not eligible for coverage. |
|
| |
| COMPLETE
FOR SECURED CREDIT OR IF YOU LIVE IN A COMMUNITY
PROPERTY STATE: |
| |
MARRIED |
|
SEPARATED
|
|
UNMARRIED
(Single - Divorced - Widowed) |
|
| APPLICANT
NAME (last - first - Initial) |
DATE
OF BIRTH |
| PRESENT
ADDRESS (Street - City - State - Zip)
|
|
|
| |
|
|
OWN
|
|
RENT
|
|
| PREVIOUS
ADDRESS (Street - City - State - Zip)
|
|
OWN
|
|
RENT
|
| |
|
|
| EMPLOYEE
NO. |
HOME
PHONE |
BUSINESS
PHONE / EXT. |
| |
( ) |
( ) |
|
| ACCOUNT
NO. |
SOCIAL
SECURITY NUMBER |
DRIVER'S
LICENSE NUMBER / STATE |
| |
|
|
|
| NUMBER
OF DEPENDENTS - EXCLUDE SELF ANY LISTED
BY CO-APPLICANT |
| |
AGES |
|
|
| ADDITIONAL
INFORMATION ABOUT YOU AND YOUR OTHER APPLICANT'S
EMPLOYMENT AND INCOME |
|
| PRESENT
EMPLOYER |
|
EMPLOYER ADDRESS (STREET, CITY, STATE, ZIP) |
| JOB
TITLE/GRADE |
SUPERVISOR |
SUPERVISOR'S
PHONE |
| |
|
|
|
|
DATE EMPLOYED |
TYPE
OF BUSINESS |
SELF
EMPLOYED |
| |
|
|
|
|
IS DUTY STATION TRANSFER EXPECTED DURING
NEXT YEAR |
WHERE |
ETS
DATE |
| |
|
|
|
|
*You
need not reveal income from alimony, child support,
or separate maintenance payments unless you want
it considered in evaluating this credit application. |
| EMPLOYMENT
INCOME |
|
OTHER
INCOME |
SOURCE
OF OTHER INCOME |
| $ PER |
|
$ PER |
|
|
| PREVIOUS
EMPLOYER(S) NAME/ADDRESS |
STARTING
DATE |
ENDING
DATE |
| |
|
|
|
|
| |
| CURRENT
DEPOSITS AT OTHER FINANCIAL INSTITUTIONS |
| ACCOUNT
NO. |
|
CHECKING |
NAME
AND INSTITUTION |
| |
|
SAVINGS |
|
|
| ACCOUNT
NO. |
|
CHECKING |
NAME
AND INSTITUTION |
| |
|
SAVINGS |
|
|
| ACCOUNT
NO. |
|
CHECKING |
NAME
AND INSTITUTION |
| |
|
SAVINGS |
|
|
| DESCRIPTION
OF CLEAR TITLE ASSETS (CAR, PROPERTY) |
VALUE |
PLEDGE
AS COLLATERAL |
| |
$ |
|
|
| (OTHER
ASSETS) |
VALUE |
PLEDGE
AS COLLATERAL |
| |
$ |
|
|
|
| |
| NAME
AND ADDRESS OF NEAREST RELATIVE NOT LIVING
WITH YOU |
| |
| RELATIONSHIP |
HOME
PHONE |
|
| NAME
AND ADDRESS OF PERSONAL FRIEND - NOT A RELATIVE |
| |
| |
HOME
PHONE |
|
|
| OTHER |
|
JOINT
APPLICANT |
|
CO-SIGNER/GUARANTOR |
|
| COMPLETE
FOR SECURED CREDIT OR IF YOU LIVE IN A COMMUNITY
PROPERTY STATE: |
| |
MARRIED |
|
SEPARATED
|
|
UNMARRIED
(Single - Divorced - Widowed) |
|
| APPLICANT
NAME (last - first - Initial) |
DATE
OF BIRTH |
| PRESENT
ADDRESS (Street - City - State - Zip)
|
|
|
| |
|
|
OWN
|
|
RENT
|
|
| PREVIOUS
ADDRESS (Street - City - State - Zip)
|
|
OWN
|
|
RENT
|
| |
|
|
| EMPLOYEE
NO. |
HOME
PHONE |
BUSINESS
PHONE / EXT. |
| |
( ) |
( ) |
|
| ACCOUNT
NO. |
SOCIAL
SECURITY NUMBER |
DRIVER'S
LICENSE NUMBER / STATE |
| |
|
|
|
| NUMBER
OF DEPENDENTS - EXCLUDE SELF ANY LISTED
BY CO-APPLICANT |
| |
AGES |
|
|
| ADDITIONAL
INFORMATION ABOUT YOU AND YOUR OTHER APPLICANT'S
EMPLOYMENT AND INCOME |
|
| PRESENT
EMPLOYER |
|
EMPLOYER ADDRESS (STREET, CITY, STATE, ZIP) |
| JOB
TITLE/GRADE |
SUPERVISOR |
SUPERVISOR'S
PHONE |
| |
|
|
|
|
DATE EMPLOYED |
TYPE
OF BUSINESS |
SELF
EMPLOYED |
| |
|
|
|
|
IS DUTY STATION TRANSFER EXPECTED DURING
NEXT YEAR |
WHERE |
ETS
DATE |
| |
|
|
|
|
*You
need not reveal income from alimony, child support,
or separate maintenance payments unless you want
it considered in evaluating this credit application. |
| EMPLOYMENT
INCOME |
|
OTHER
INCOME |
SOURCE
OF OTHER INCOME |
| $ PER |
|
$ PER |
|
|
| PREVIOUS
EMPLOYER(S) NAME/ADDRESS |
STARTING
DATE |
ENDING
DATE |
| |
|
|
|
|
| |
| CURRENT
DEPOSITS AT OTHER FINANCIAL INSTITUTIONS |
| ACCOUNT
NO. |
|
CHECKING |
NAME
AND INSTITUTION |
| |
|
SAVINGS |
|
|
| ACCOUNT
NO. |
|
CHECKING |
NAME
AND INSTITUTION |
| |
|
SAVINGS |
|
|
| ACCOUNT
NO. |
|
CHECKING |
NAME
AND INSTITUTION |
| |
|
SAVINGS |
|
|
| DESCRIPTION
OF CLEAR TITLE ASSETS (CAR, PROPERTY) |
VALUE |
PLEDGE
AS COLLATERAL |
| |
$ |
|
|
| (OTHER
ASSETS) |
VALUE |
PLEDGE
AS COLLATERAL |
| |
$ |
|
|
|
| |
| NAME
AND ADDRESS OF NEAREST RELATIVE NOT LIVING
WITH YOU |
| |
| RELATIONSHIP |
HOME
PHONE |
|
| NAME
AND ADDRESS OF PERSONAL FRIEND - NOT A RELATIVE |
| |
| |
HOME
PHONE |
|
|
| OUTSTANDING
DEBTS AND OBLIGATIONS - LIST EVERYTHING OWED,
USE SEPARATE SHEET IF NEEDED |
|
CHECK
ONE
OR MORE |
NAME
& ADDRESS OF CREDITOR |
ACCT.NO. |
PAST
DUE |
ORIGINAL
AMOUNT |
BALANCE |
MONTHLY
PAYMENT |
| |
HOUSE
PAYMENT OR RENT |
|
|
$ |
$ |
$ |
| |
HOUSE
PAYMENT OR RENT |
|
|
$ |
$ |
$ |
| |
AUTO
LOAN |
|
|
$ |
$ |
$ |
| |
AUTO
LOAN |
|
|
$ |
$ |
$ |
| |
DEPARTMENT
STORES |
|
|
$ |
$ |
$ |
| |
|
|
|
$ |
$ |
$ |
| |
|
|
|
$ |
$ |
$ |
| |
|
|
|
$ |
$ |
$ |
| |
CHILD
SUPPORT |
|
|
$ |
$ |
$ |
| |
CHILD
CARE |
|
|
$ |
$ |
$ |
| |
CREDIT
CARDS |
|
|
$ |
$ |
$ |
| |
|
|
|
$ |
$ |
$ |
| |
|
|
|
$ |
$ |
$ |
| |
|
|
|
$ |
$ |
$ |
| |
LOAN
PAYMENTS |
|
|
$ |
$ |
$ |
| |
|
|
|
$ |
$ |
$ |
| |
|
|
|
$ |
$ |
$ |
| |
|
|
|
$ |
$ |
$ |
| |
MISC.
EXPENSES (UTILITIES, TELEPHONE, INSURANCE, ECT.)
|
|
|
$ |
$ |
$ |
| ATTACH
SEPARATE SHEET IF NECESSARY |
TOTALS |
$ |
$ |
$ |
| |
APPLICANT |
OTHER |
| HAVE
YOU EVER FILED A PETITION FOR BANKRUPTCY (PERSONAL
OR BUSINESS)? |
|
|
| HAVE
YOU EVER FILED A PETITION FOR CHAPTER 13 BANCKRUPTCY? |
|
|
| ARE
ANY SUITS PENDING, JUDGEMENTS FILED< ALIMONYS
OR SUPPORT AWARDS AGANIST YOU? |
|
|
| HAVE
YOU HAD ANY AUTO, FURNTURE, OR ANY PROPERTY REPOSSESSED? |
|
|
| ARE
YOU PARTY IN A LAWSUIT? |
|
|
| DO
YOU HAVE ANY OUTSTANDING JUDGEMENTS? |
|
|
| IS
ANY INCOME YOU HAVE SHOWN LIKELY TO RUDUCE IN
THE NEXT TWO YEARS? |
|
|
| ARE
YOU A CO-MAKER OR CO-SIGNER ON ANY LOAN? IF SO,
WHOM? |
|
|
|
NAME OF OTHERS OBLIGATED ON LOAN AND NAME OF CREDITOR |
|
|
| IF
ANY YES ANSWERS TO QUESTIONS, EXPLAIN ON SEPARATE
SHEET |
|
|
|
ARE
YOU A UNITED STATES CITIZEN?
| |
APPLICANT |
OTHER |
| APPLICANT |
|
|
| OTHER
APPLICANT |
|
|
| ......IF
NO LIST STATUS |
|
| A
$10.00 APPLICATION FEE WILL BE CHARGED FOR SIGNATURE
LOANS. A $15.00 APPLICATION FEE WILL BE CHARGED FOR
COLLATERAL LOANS |
| It
is the Credit Union's
You
agree that everything you have stated in this application
is correct to the best of your knowledge. If there
are any important changes you will notify use in writing
immediately. You authorize the Credit Union to obtain
credit reports in connection with this application
for credit and any update, increase, 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.
a. |
| X |
__________________________________________ |
X |
__________________________________________ |
| |
Applicants
Signature Date |
|
Other
Signature Date |
|
FOR OFFICIAL USE ONLY |
| Signatures |
Date |
Amount Approved |
|
You
Must Print, Sign, and Mail or Fax to Credit Union:
| Address: |
Piedmont Hospital FCU
1968 Peachtree Rd., NW
Atlanta, GA 30309 |
| Fax
Number: |
404-609-6776
|
|