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

Date you'd like payments to begin:   
(maximum delay is 30 days)
immediately    delayed

Would you like disability insurance? 
cost approx. $.063 per day per $1,000.00
yes   no

Would you like life insurance?      
cost approx. $.021 per day per $1,000.00 for joint life
yes    no


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
Mastercard
Mastercard
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

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