Secure Loan Application Form
2204 Rosa L. Parks Blvd. Nashville, TN 37228 
Phone: (615) 749-6461 | Fax: (615) 749-6345

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.

Account / Loan: Individual Joint

Loan Type:

Amount Requested: $ .00             Purpose / Collateral:
(Including ATM/ Debit Card Access to the Account if available)

Repayment: Payroll Deduction Cash Military Allotment Automatic Payment


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                                              Joint Credit Disability                                              None
Single Credit Life Insurance                                      Joint Credit Life Insurance                                      None

Applicant Information
Applicant's Name:
Account #:
Driver License #:
Social Security #:
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:
Email :
Home Phone #:
Mobile Phone #:
Street Address:
City: State:
Zip #:
Current Address since: (MM/YY)
Rent     Own     Payment:
If less than 3 yrs enter previous address:
Joint Applicant's Name:
Account #:
Driver License #:
Social Security #:
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:
Email :
Home Phone #:
Mobile Phone #:
Street Address:
City: State:
Zip #:
Current Address since: (MM/YY)
Rent     Own     Payment:
If less than 3 yrs enter previous address:

Employment Information
Applicant Employer's Name:
Employer Phone #:
Employer Address:
Department:
Supervisor:
Position:
Date Hired (MM/DD/YY):
Monthly Gross Income ($):
Other Income ($): per Month
Complete if current employment is less than 2 years:
Previous Employers Name:
Yrs Employed:
Joint App. Employer's Name:
Employer Phone #:
Employer Address:
Department:
Supervisor:
Position:
Date Hired (MM/DD/YY):
Monthly Gross Income ($):
Other Income ($): per Month
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
Child Support Payments / Alimony $
Other Assets:
     Auto Year: Auto Make: Auto License Plate: Description:
    
     Auto Year: Auto Make: Auto License Plate: Description:
    
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?

State Law Notices

Notice to Nebraska Residents: A credit agreement must be in writing to be enforceable under Nebraska law. To protect you and us from any
misunderstandings or disappointments, any contract, promise, undertaking, or offer to forebear repayment of money or to make any other financial
accommodation in connection with this loan of money or grant or extension of credit, or any amendment of, cancellation of, waiver of, or substitution for
any or all of the terms or provisions of any instrument or document executed in connection with this loan of money or grant or extension of credit, must
be in writing to be effective.

Notice to New York Residents: New York residents may contact the New York State Department of Financial Services to obtain a comparative listing
of credit card rates, fees, and grace periods. New York State Department of Financial Services: 1-800-342-3736 or www.dfs.ny.gov.
Notice to Ohio Residents: 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.

Notice to Wisconsin Residents: (1) No provision of any marital property agreement, unilateral statement under Section 766.59, 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 your spouse. The credit being applied for, if granted, will be incurred in the interest of the marriage or family of the undersigned.

Date:
Signature for Wisconsin Residents Only:

Consensual Security Interest

You grant us a security interest in all individual and joint share and/or deposit accounts you have with us now and in the future to secure your credit card account. Shares and deposits in an IRA or any other account that would lose special tax treatment under state or federal law if given as security are not subject to the security interest you have given in your shares and deposits. You may withdraw these other shares unless you are in default. When you are in default, you authorize us to apply the balance in these accounts to any amounts due. For example, if you have an unpaid credit card balance, you agree we may use funds in your account(s) to pay any or all of the unpaid balance.

By signing or otherwise authenticating below, you are affirmatively agreeing that you are aware that granting a security interest is a condition for the credit card and you intend to grant a security interest. You acknowledge and agree that your pledge does not apply during any periods when you are a covered borrower under the Military Lending Act. For clarity, you will not be deemed a covered borrower, and your pledge will apply, if: (i) you become obligated on a credit transaction or establish an account for credit when you are not a covered borrower; or (ii) you cease to be a covered borrower.

Date:
Primary Signature:
Joint Signature:

Submit Application

By signing or otherwise authenticating below:
1. You promise that everything you have stated in this application is correct to the best of your knowledge. If there are any important changes you will
notify us in writing immediately. You authorize the Credit Union to obtain credit reports in connection with this application for credit and for any
update, increase, renewal, extension, or collection of the credit received. You understand that the Credit Union will rely on the information in this
application and your credit report to make its decision. If you request, the Credit Union will tell you the name and address of any credit bureau from
which it received a credit report on you. It is a crime to willfully and deliberately provide incomplete or incorrect information in this application.

2. If you are applying for a credit card, you understand that the use of your card will constitute acknowledgment of receipt and agreement to the terms
of the Consumer Credit Card Agreement and Disclosure.

Date:
Primary Signature:
Joint Signature: