Secure Loan Application
53 Weed Street, Plattsburgh, NY 12901
Phone: (518) 563-1338 • Fax: (518) 563-1699


1. Type Of Loan Applying For
Requested Amount: $ .00
Requested Term:
 
2. 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
Single Credit Life Insurance
Joint Credit Life Insurance
No Insurance
  
3. Applicant Information
Applicant:

US Citizen Yes No
Name:
Account #:
Social Security #:
Birthdate (MM/DD/YY):
Please indicate your marital status if you are applying for joint credit, secured credit or if you live in a community property state:
Married Separated Unmarried (single-divorced-widowed)
Home Phone #:
Cell Phone #:
Present Address:
Street:
City:
State & Zip:
Current Address since: (MM/YY)
If less than 3 yrs enter previous address:

Joint Applicant:

US Citizen Yes No
Name:
Account #:
Social Security #:
Birthdate (MM/DD/YY):
Please indicate your marital status if you are applying for joint credit, secured credit or if you live in a community property state:
Married Separated Unmarried (single-divorced-widowed)
Home Phone #:
Cell Phone #:
Present Address:
Street:
City:
State & Zip:
Current Address since: (MM/YY)
If less than 3 yrs enter previous address:

  
4. Employment Information
The Credit Union requires proof of income. Please drop off paystubs or fax to 518-563-1699. If self-employed or retired, please contact the credit union to see what type of proof of income we require.
Applicant:

Employer Name:

Employer Phone #:
Employer Address:


Supervisor:
Position:
Date Hired (MM/DD/YY):
Monthly Gross Income $

Complete if current employment is less than 2 years:
Previous Employers Name:

Yrs Employed:

Joint Applicant:

Employer Name:

Employer Phone #:
Employer Address:


Supervisor:
Position:
Date Hired (MM/DD/YY):
Monthly Gross Income $

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.

5. Debts & Assets
Estimated Value Of Your Home: $ .00
Estimated Value Of Your Vehicles: $ .00
Lender
Type
Balance
Min. Pmt.
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
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?
   
6. References
Nearest Relative NOT Living with you:
  Name:
First: Middle: Last: Suffix:
   Home Phone Number:
555-555-5555
   What is their home address?
Street: City: State: Zip:
   What is the relationship?

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 and 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 force and 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 your signature on additional documents prior to disbursing any credit proceeds.     

Submit Application