Apply for a Loan * Required Fields Loan Request Amount Requested: This form cannot be used to apply for home equity or mortgage loans. Please contact our real estate department at 607-936-2293 for additional information. Additional documentation may be required such as Dealer/Seller information, Insurance agent name and address or copies of statements for creditors. Proof of income may also be required. Please fax to 607-936-3154. After submission of this form please allow up to two business days for response. Loan Information Amount Requested:: Time to Repay:: Periods: Select... Years Months Loan Type:: Select... Boat Camper Personal Debt Consolidation Home Improvement Motorcycle New Auto Recreational Vehicle Used Auto Other Security Offered (For secured credit only): Type of Credit:: Individual Joint Payment Protection Coverage Check coverage(s) desired. We will disclose the cost of this payment protection insurance - Credit Disability and Credit Life - to you. A separate enrollment form which discloses the terms and conditions must be signed for coverage to become effective. Do you want your loan protected for you and your family in the event you become disabled? Yes No Do you want your loan protected for you and your family in the event of your death? : Yes No Tell Us About Yourself And The Co-Applicant Co-applicant information should be provided if:• Your spouse will use the account.• You are relying on your spouse's income as a basis of repayment,• If you are relying on income from alimony, child support or separate maintenance income, complete the Co-Applicant section to the extent possible about the person on whose payments you are relying.• If you are applying for Joint Credit with another person.• You are living in or the property pledged as collateral is located in a community property state (AZ, CA, ID, LA, NM, NV, TX, WA and WI). Your Name: Your Birth Date: Your Birth Date: Month Month... January February March April May June July August September October November December / Your Birth Date: Day Day... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 / Your Birth Date: Year Year... 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 2043 2044 2045 Your Account Number #: Marital Status: Select... Married Unmarried Separated Social Security #: Drivers License #: DL State: Address: Address 2: City: State: Select... AL AK AZ AR CA CO CT DE DC FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY ZIP: Years at Address: Own or Rent: Own Rent/other Work Phone: Home Phone: Mobile Phone: Email: Mortgage Owed To: Monthly Mortgage: Person Responsible for Mortgage: Mortgage Balance: Mortgage APR: Credit Card 1: Balance: Monthly Payment: Credit Card 2: Balance: Monthly Payment: Other Owed To 1: Original Amount: Unpaid Balance: Monthly Payment: Other Owed To 2: Original Amount: Unpaid Balance: Monthly Payment: Your Employer: Your Income: Net or Gross: Net Gross Other Income Source: Amount: Final Confirmation By clicking Yes below you authorize the Credit Union to obtain credit reports in connection with this application for credit and for any update, renewal or extension of the credit received. You understand 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. Applicant's Confirmation: Yes Co-Applicant Confirmation: Yes Security Code: Security Code
