Account Number:

Name:

Social Security #:

Birth Date:

Address:

Phone Number:

Loan Purpose:

Loan Amount:

Length of Loan (in months):

Payment Type:

Biweekly

Monthly

Income Information Income verification will be required. Alimony, child support, or separate maintenance payments need not be revealed if you do not wish to have it considered as basis for repaying this obligation.

Employer:

Work Phone :

Length of Employment:

Income:   $		per		Other Income:   $		per
				(List alimony, child support, and maintenance payments separately)

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Current Credit History
	Credit Type					Payment
		Rent		Mortgage	$

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Co-maker Information (Complete if necessary)

Account Number:

Name:

Social Security #:

Birth Date:

Address:

Phone Number:

Income:   $

per

Employer:		Work Phone :

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Notes Use the box below if you would like to include any additional information that you think may help us in making our decision for the loan you are applying for:

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Notice I hereby authorize the Credit Union to whom this application is made, or any Credit Bureau or other investigative agency employed by such Credit Union, to investigate the references herein listed or statements or other data obtained from me or from any other source whatsoever pertaining to my credit and financial responsibility. The New York laws against discrimination require that all creditors make credit equally available to all credit worthy customers and that credit reporting agencies maintain separate credit histories on each individual upon request. The New York Civil Rights Commission administers compliance with this law.