Secure Loan Application
160 EAST FIRST AVENUE. P.O. BOX 128
DERRY, PA 15627
Phone: (724)694-5479  •  Fax: (724)694-0570
Latrobe Branch Phone: (724) 539-1856


Type Of Loan Applying For

New or Used Vehicle Loan
Recreational Vehicle (Camper, ATV, Motorcyle, etc.)


Purpose of loan:
Requested Amount : $ .00

Repayment: Direct Deposit    Cash    Automatic Payment    Payroll Deduction    Military Allotment


Payment Protection Coverage
Check coverage(s) desired. The Credit Union will disclose the cost of this voluntary insurance to you. A separate enrollment form which discloses the terms and conditions must be signed for coverage to become effective.
Single Credit Life Insurance                              Joint Credit Life Insurance                              None
Credit Disability Insurance

Applicant Information
Applicant's Name:
Account #:
Social Security #:
US Citizen: Yes No
Birthdate (MM/DD/YY):
Email Address :
Number of Dependants :
We consider the primary borrower one dependent, a spouse would be the second dependent and then children would be subsequent dependents.
Home Phone #:
Mobile Phone #:
Address :
City : State:
Zip #:
Current Address since: (MM/YY)
Rent     Own     Payment:
If less than 3 yrs enter previous address:
Number of months at residence:
Joint Applicant's Name:
Is Joint Applicant your spouse? Yes No
Account #:
Social Security #:
US Citizen: Yes No
Birthdate (MM/DD/YY):
Email Address :
Number of Dependants :
We consider the primary borrower one dependent, a spouse would be the second dependent and then children would be subsequent dependents.
Home Phone #:
Mobile Phone #:
Address :
City : State:
Zip #:
Current Address since: (MM/YY)
Rent     Own     Payment:
If less than 3 yrs enter previous address:
Number of months at residence:

Employment Information
Applicant Employer's Name:
Employer Phone #:
Employer Address :
Position:
Status: Full Time Part Time
Date Hired (MM/DD/YY):
Hourly Wage / Month Salary ($):
Other Income ($): per Month
Other Income Source :
Prev. Employers Name:
Prev. Job Start Date:
Prev. Job End Date:
Joint App. Employer's Name:
Employer Phone #:
Employer Address :
Position:
Status: Full Time Part Time
Date Hired (MM/DD/YY):
Hourly Wage / Month Salary ($):
Other Income ($): per Month
Other Income Source :
Prev. Employers Name:
Prev. Job Start Date:
Prev. Job End Date:



Personal Financial Profile
Lender
Type
Balance
Min. Pmt.
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
Child Support Payments / Alimony $
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?
Are you a U.S. citizen or permanent resident alien?

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?

Submit Application

Preferred branch location for closing loan?

I/We understand that credit union membership is required to fully process this loan application and further documentation / signatures may be required. By submitting this form with your electronic signature(s), you agree that everything stated in this application is correct to the best of your knowledge and grant permission to Derry Area FCU to perform the following. Derry Area FCU is authorized to validate your information, investigate your creditworthiness, employment history, and obtain a credit report. 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. Derry Area FCU may keep this application whether or not it is approved.

By pressing the "Submit Application" button below, you agree to the above statement.  

To avoid delays in processing your request please provide us with the best method of contact:
Home Phone      Mobile Phone      Work Phone


Date:
Primary Signature:
Joint Signature: