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Secure Loan Application Form

P.O. Box 11197, Daytona Beach, FL 32120-1197
Phone: (386) 506-3040 | Fax: (386) 226-0431

MasterCard Loan Application, Located Here!
   
Type Of Loan Applying For

Individual Credit: You must complete the Applicant section about yourself and the Other section about your spouse if:

  1. you live in or the property pledged as collateral is located in a community property state (AK, AZ, CA, ID, LA, NM, NV, TX, WA, WI)
  2. your spouse will use the account, or
  3. you are relying on your spouse's income as a basis for repayment. If you are relying on income from alimony, child support, or separate maintenance, complete the Other section to the extent possible about the person on whose payments you are relying.

Joint Credit: Each Applicant must individually complete the appropriate section below, If Co-Borrower is spouse of the Applicant,- mark the Co-Applicant box.

Guarantor: Complete the Other section if you are a guarantor on an account/loan.
Check below to indicate the type of account(s) and type of credit for which you are applying. Married Applicants may apply for a separate account.

Are you applying for individual or joint credit ?: Individual    Joint

Type of Loan:

Amount Requested: $ .00

Term in Months:



Applicant Information
Applicant's Name:
Account #:
Driver License #:
Social Security #:
Email:
US Citizen: Yes No
Birthdate (MM/DD/YYYY):
Home Phone #:
Cell Phone #:
Street Address:
City: State:
Zip #:
Current Address since: (MM/YY)
Monthly Housing Payment: $
If less than 3 yrs enter previous address:
Joint Applicant's Name:
Account #:
Driver License #:
Social Security #:
Email:
US Citizen: Yes No
Birthdate (MM/DD/YYYY):
Home Phone #:
Cell Phone #:
Street Address:
City: State:
Zip #:
Current Address since: (MM/YY)
Monthly Housing Payment: $
If less than 3 yrs enter previous address:


Employment Information
Applicant Employer's Name:
Employer Phone #:
Position:
Date Hired (MM/DD/YY):
Monthly Gross Income ($):
Other Monthly Income ($):
Joint App. Employer's Name:
Employer Phone #:
Position:
Date Hired (MM/DD/YY):
Monthly Gross Income ($):
Other Monthly Income ($):
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.


Other Information
Assets:
Description: Value:
    
Description: Value:
    
Have you ever filed for bankruptcy or had debt adjustment under Chapter 13?
   Are you a party in a lawsuit?
   Have you ever had property foreclosed or repossesion in the last 7 years?
   Is your income likely to decline in the next two years?
Are you co-maker/endorser on any loan not listed above?
   If yes then for whom?
   If yes then to whom?


References (Nearest relative not living with you)
First Name: Middle Name: Last Name: Suffix:
   Home Phone Number:
   555-555-5555
   What is their home address?
Street: City: State: Zip:
   What is the relationship?


 
References
First Name: Middle Name: Last Name: Suffix:
   Home Phone Number:
   555-555-5555
   What is their home address?
Street: City: State: Zip:
   What is the relationship?


Contact Method
  How would you prefer to be contacted? Home Phone Cell Phone Email
 
  Additional Comments:


Submit Application

State Law Notices
OHIO RESIDENTS ONLY: The Ohio laws against discrimination require that all creditors make credit equally available to all creditworthy customers, and that credit reporting agencies maintain separate credit histories on each individual upon request. The Ohio Civil Rights Commission administers compliance with this law.
WISCONSIN RESIDENTS ONLY: (1) No provision of any marital property agreement, unilateral statement under Section 768.59, or court decree under Section 766.70 will adversely affect the rights of the Credit Union unless the Credit Union is furnished a copy of the agreement, statement or decree, or has actual knowledge of its terms, before the credit is granted or the account is opened. (2) Please sign if you are not applying for this account or loan with spouse. The credit being applied for, if granted, will be incurred in the interest of the marriage or family of the undersigned.

Equal Credit Opportunity Act Policy: ECOA prohibits discrimination against credit applicants or co-applicants on the basis of race, color, religion, national origin, sex, marital status, age, receipt of income from a public assistance program, or the good faith exercise of any right under the Federal Consumer Credit Protection Act.

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 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 forceand effect as your original signature. You assume any risk that may be associated with permitting us to accept your facsimile signature.

By pressing the "Submit Application" button below, you agree to the above statement. You understand that we may require additional information to finalize our credit decision and your signature on additional documents prior to disbursing any credit proceeds.