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Loan Application

THIS IS A SECURE DOCUMENT
Please Enter your Email Address:

If you are applying for joint credit, secured credit or if you live in a community property state (AZ,CA,ID,LA,NM,NV,TX,WA,WI,Puerto Rico), please complete the following:
Married Separated Unmarried (Single, Divorced, Widowed)

Type of Loan Applied For:
Personal (Signature) Share Secured
Home Equity New Vehicle Used Vehicle
Other:

Amount applied for: $
Purpose:
Desired Length of Repayment (mon):

Method of Payment:
Coupons Payroll Deduction Automatic Transfer from Shares Drafts

Payment Protection Plan:
Would you like to purchase Credit Life Insurance?
Single Credit Life
Joint Credit Life
None

Would you like to purchase Credit Disability Insurance? (choose one)
Applicant
Co-Applicant
None

Applicant:

 Name:
Account #:
Social Security #:
Drivers License #: State:
Birthdate (MM/DD/YY):
Mother's Maiden Name:
Home Phone #:
Present Address:
Street:
City: State:
Zip:
Current Address since: (MM/YY)
If less than 3 yrs enter previous address:

Joint Applicant:

 Name:
Account #:
Social Security #:
Drivers License #: State:
Birthdate (MM/DD/YY):
Mother's Maiden Name:
Home Phone #:
Present Address:
Street:
City: State:
Zip:
Current Address since: (MM/YY)
If less than 3 yrs enter previous address:
Employment and Income: In order to expedite the processing of your loan application please fax your paystub copies to
(610) 691-8624, Attention: Loan Department. If self-employed or retired, financial statement or income tax returns will be needed.
Employer Name:

Employer Phone #:
Employer Address:

Position:
Date Hired (MM/DD/YY):
Monthly Gross Income: $
Hours At Work:
Other Income: $ per Month 		Employer Name:

Employer Phone #:
Employer Address:

Position:
Date Hired (MM/DD/YY):
Monthly Gross Income: $
Hours At Work:
Other Income: $ per Month
NOTE: Alimony, child support, or separate maintenance income need not be revealed if you do not choose to have it considered as a basis for this credit request.
Complete if current is less than 2 years:
Previous Employers Name:

Years Employed: 		Complete if current is less than 2 years:
Previous Employers Name:

Years Employed:
Credit Information
Creditor Monthly
Payment
Housing
Rent Own None 		$
$
$
$
$
$
$
$
$
$
$
$
Creditor Monthly
Payment
Housing
Rent Own None		 $
$
$
$
$
$
$
$
$
$
$
$
You agree that everything stated in this application is correct to the best of your knowledge. The Credit Union is authorized to investigate your creditworthiness, employment history, and to obtain a credit report and to answer questions about their credit experience with you. You understand that any false or misleading statement in your application may cause any loan or extension of credit to be in default. You authorize us to accept your facsimile signatures on this application and agree that your facsimile signature will have the same legal force and effect as your original signature. You assume any risk that may be associated with permitting us to accept your facsimile signature.

By pressing the "Send Request" button below, you agree to the above statement. You understand that we may require your signature on additional documents prior to disbursing any credit proceeds.
Bethlehem 1st Federal Credit Union