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


Account Number - If You Are A Member Amount Requested Type Of Loan Applying For Term

$ Months
 

Individual Credit:
Complete Applicant sections if only the applicant's income is considered for loan approval. Complete Applicant and Co-Applicant sections: (1) if you are relying on income from alimony, child support, or separate maintenance or on the income or assets of another person as the basis for repayment of credit requested; (2) if you reside in a Community Property State; (3) if you are relying on property located in a Community Property State as a basis for repayment of the credit requested; or (4) if you are an Alaska resident subject to a community property agreement or community property trust. Community Property States include: AZ, CA, ID, LA, NM, NV, TX, WA, WI.

Joint Credit:
Complete Applicant and Co-Applicant sections if your co-applicant will be contractually liable for repayment of the loan and initial below: We intend to apply for joint credit. (Applicant Initials)         (Co-Applicant Initials)


PRIMARY APPLICANT
 
JOINT APPLICANT

Name: First, Middle, Last

Name: First, Middle, Last
Social Security Number:
Date of Birth:
 
Social Security Number:
Date of Birth:
What Is Your Email Address?
  What Is Your Email Address?
Home Phone Number:
Cell Phone Number:
I Can Be Best Reached Via:
 
Home Phone Number:
Cell Phone Number:
I Can Be Best Reached Via:
What Is Your Home Address?
Street: City:
  What Is Your Home Address?
Street: City:
State: Zip:
 
State: Zip:
Monthly Housing Payment: $   Monthly Housing Payment:  $
Current Employer:
Business Phone:
 
Current Employer:
Business Phone:
Gross Salary: $       Gross Salary: $    
Frequency:   Frequency:
Other Income: $   Other Income: $
Frequency:   Frequency:
Source Of Income:   Source Of Income:
 
REFERENCES
Nearest Relative NOT Living with you:
Name: First: Middle: Last: Suffix:
Home Phone: What is the relationship?
What is their home address?
Street: City: State: Zip:
Nearest Relative NOT Living with you:
Name: First: Middle: Last: Suffix:
Home Phone: What is the relationship?
What is their home address?
Street: City: State: Zip:
OTHER INFORMATION
(You do not need to provide information about alimony, child support, separate maintenance or other sources of income if you do not wish to have them considered as income.)
 
Have You Filed For Bankruptcy? Are You A U.S. Citizen Or Permanent Resident Alien?
Are You  A Co-Maker/Endorser On Any Loan?
If Yes, Then For Whom? Balance:
Do You Currently Have Any Outstanding Judgements Or Have You Had A Debt Adjustment, Repossession, Or Property Foreclosed In The Last 7 Years Or Are A Party To A Lawsuit?

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.