PO Box 216, St Maries ID 83861

Phone: (208) 245-4231 • Fax: (208) 245-5341

Secure Loan Application Form

Type Of Loan Applying For

Individual Credit: You must complete the Applicant section about yourself and the Other section about your spouse if:

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)
your spouse will use the account, or
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, select Joint (Spousal) in the Application Type.

Account No:

Application Type:

Desired Loan Type:

Desired Loan Amount:

Desired Loan Term (Months):

Complete the following information if your request is for a vehicle:

Type:

Year of Vehicle:

Make:

Model:

Vehicle Mileage:

Purchase Price:

If refinancing, current payoff:

I am interested in GAP insurance on loan:

Yes No

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.

Credit Life:

Single Joint None

Disability:

Single Joint None

Primary Applicant

Applicant Information

Applicant's Name:

Driver License #:

Drivers License State:

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 Addres:

City:

State:

Zip Code:

Current Address since:

If less than 3 yrs enter previous address:

Employment Information

Employer's Name:

Employer Phone:

Employer Address:

Job Title:

Date Hired:

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.

Joint Applicant

Joint Applicant Information

Applicant's Name:

Driver License #:

Drivers License State:

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 Addres:

City:

State:

Zip Code:

Current Address since:

If less than 3 yrs enter previous address:

Joint Applicant Employment Information

Employer's Name:

Employer Phone:

Employer Address:

Job Title:

Date Hired:

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.

References (Nearest relative not living with you)

First Name:

Middle Name:

Last Name:

Suffix:

Home Phone:

Cell Phone:

What is their home address?

Street:

City:

State:

Zip Code:

First Name:

Middle Name:

Last Name:

Suffix:

Home Phone:

Cell Phone:

What is their home address?

Street:

City:

State:

Zip Code:

Contact Method

How would you prefer to be contacted?

Home Phone Cell Phone Email

Additional Comments:

Submit Application

State Law Notices

OHIO RESIDENTS ONLY: 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.

WISCONSIN RESIDENTS ONLY: (1) No provision of any marital property agreement, unilateral statement under Section 768.59, 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 spouse. The credit being applied for, if granted, will be incurred in the interest of the marriage or family of the undersigned.

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 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 Form" button below, you agree to the above statement. You understand that we may require additional information to finalize our credit decision and your signature on additional documents prior to disbursing any credit proceeds.