Secure Loan Application
2318 W Willow Knolls Drive, Peoria, IL 61614
Phone: (309) 693-6000  •  Fax: (309) 693-7312

Note: All fields with an asterisk (*) indicate required fields that must be completed before submitting your application.

Type Of Credit Requested
Select Desired Loan Type:
I/We would like a loan in the amount of:
$
Marital Status:
Account Number #:
PRIMARY APPLICANT INFORMATION
  Married Unmarried Separated
*First Name:
Middle Initial:
*Last Name:
Date of Birth:
*Social Security Number:
Drivers License or ID #:
Drivers License State:
*Home Phone Number:
*Cell Phone Number:
*Email Address:
I Can Best Be Reached Via:
*Street Address:
*City:
*State: *Zip:
How Long At Current Address:
Years    Months
Type Of Housing:

Employment
*Present Employer:
Business Phone:
Employer's Address:
State: Zip:
Date Employed:
*Job Title:
How Many Hours Are You Sceduled To Work:
per week
*Gross Salary:
$
Frequency:
Other Income:
$
Source Of Other Income:

Reference
Nearest Relative (Not  Living With You):
First Name: MI: Last Name:
Relationship:
Phone:
Address:
City:
State: Zip:

Other Information
Have you filed for bankruptcy? Yes No

Are you a US Citizen or Permanent Resident Alien? Yes No

Are you a Co-Maker/Endorser on any loan? Yes No
  If yes, then for whom?
  Balance: $

Do you currently have any outstanding judgments or have you had a debt adjustment, repossession or property foreclosed upon in the last 7 years? Yes No

Are you a party involved in a lawsuit? Yes No

Do you have an obligation to pay alimony/child support? Yes No
  If Yes, Amount
$
  per

LIST ALL EXISTING DEBTS & ASSETS
List Financial Institutions, Savings: Amount: List Financial Institutions, Checking: Amount:
Please tell us about your debts:
Lender
Type
Balance
Min. Pmt.
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
   
Payment Method: I would like payroll deduction
  I would like a payment booklet
  I would like the payment transferred from my Kemba Account
              Select Desired Account: Checking Savings
   
Vehicle Information:  
Type:
N/A Purchase Vehicle Refinance Vehicle
Year Of Vehicle:
Make:
Model:
Vehicle Identification #:
Vehicle Mileage:
Purchase Price:
$
Down Payment:
$
Current Payment On Trade In:
$
   
I am interested in GAP and/or MRC Insurance on the loan: Yes No
 
   
CO-APPLICANT INFORMATION
 
First Name:
Middle Initial:
Last Name:
Date of Birth:
Social Security Number:
Drivers License or ID #:
Drivers License State:
Home Phone Number:
Cell Phone Number:
Email Address:
I Can Best Be Reached Via:
Street Address:
City:
State: Zip:
How Long At Current Address:
Years    Months
Type Of Housing:

 
Present Employer:
Business Phone:
Employer's Address:
State: Zip:
Date Employed:
Job Title:
How Many Hours Are You Sceduled To Work:
per week
Gross Salary:
$
Frequency:
Other Income:
$
Source Of Other Income:

Loan Protection Insurance: I Would Like Credit Life Insurance On This Loan. 
  I Would Like Credit Disability On This Loan.

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.