Kemba Peoria Home Page

Secure Loan Application Form

2318 W Willow Knolls Drive, Peoria, IL 61614
Phone: (309) 693-6000 | Fax: (309) 693-7312
   
Type Of Loan Applying For

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

Type:

Amount Requested: $ .00       Collateral:

Repayment: Payroll Deduction Payment Booklet Automatic Payment from KEMBA Account


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 Disability       None
Single Credit Life Insurance       Joint Credit Life Insurance       None


Applicant Information
Applicant's Name:
Account #:
Driver License #:
Social Security #:
Email:
US Citizen: Yes No
Birthdate:
Please indicate your marital status if you are applying for joint credit, secured credit or if you live in a community property state:
Marital Status:
Home Phone #:
Cell Phone #:
Street Address:
City: State:
Zip #:
Current Address since: (MM/YY)
If less than 3 yrs enter previous address:
Joint Applicant's Name:
Account #:
Driver License #:
Social Security #:
Email:
US Citizen: Yes No
Birthdate:
Please indicate your marital status if you are applying for joint credit, secured credit or if you live in a community property state:
Marital Status:
Home Phone #:
Cell Phone #:
Street Address:
City: State:
Zip #:
Current Address since: (MM/YY)
If less than 3 yrs enter previous address:


Employment Information
Applicant Employer's Name:
Employer Phone #:
Employer Address:
Position:
Date Hired (MM/DD/YY):
Monthly Gross Income ($):
Other Income ($): per Month
Other Income Source:
Complete if current employment is less than 2 years:
Previous Employers Name:
Yrs Employed:
Joint App. Employer's Name:
Employer Phone #:
Employer Address:
Position:
Date Hired (MM/DD/YY):
Monthly Gross Income ($):
Other Income ($): per Month
Other Income Source:
Complete if current employment is less than 2 years:
Previous Employers Name:
Yrs Employed:
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.


Debts & Assets
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?


Vehicle Information
Type:
Year of Vehicle: Make: Model:
VIN: Milage: Purchase Price: $
Down Payment: $ Current Payment on trade in: $ I am interest in GAP and/or MRC Insurance on the loan: Yes No


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?


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


Submit Application

APPLICATION AUTHORIZATION

PLEASE READ BEFORE SUBMITTING:
You agree that everything stated in this application is true.  I understand that section 1014 Title 18 US Code makes it a federal crime to knowingly make a false statement on this application. 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 our facsimile signature(s) 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. 

NOTE:  A current wage stub showing year to date information or other income documentation will be required for loan processing.  Please fax this to (309) 693-7312 after submitting your loan application.

By pressing the “Submit Application” button below, you agree to the above statement. (If this application includes a co-applicant, this statement applies to both of us.) You understand that we may require additional information to finalize our credit decision and your signature(s) on additional documents prior to disbursing any loan proceeds.

Have you omitted anything?  Remember:  Incomplete applications will not be processed.