Northside FCU
Northside Federal Credit Union

 Applicant Information
Applicant's Name ___________________________________
Home Address_____________________________________ 
City_________________________________ State _____________ Zip_____________   
Home Phone _______________________ Years At This Address ______________
Date of Birth________________________ Number of Dependants ______________
Hospital Department____________________ Shift ________________
Job Title__________________________ Hospital Extension # _______________
 Employment Information (Applicant)
If employed less than one year, please indicate:
Previous Employer _________________________       
Length of Employment_____________      Reason for Leaving _________________
Employer Address
State______        Zip _____________  
Applicant's Current Gross Salary $_________________
Date of Hire ____________________
Marital Status: Complete this if loan is for:
a. Joint or Secured Credit, or
b. You reside in or rely on property in a Community Property State (AZ, CA, ID, LA, NM, NV, TX, WA)
Other Income*______________________________ Source of Income _____________________
* Alimony, child support or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this loan.
Name of Relative (other than spouse) who would be able to contact you at all times:
Name _________________________________________________
Relationship____________________________________________ Home Phone __________________________
Address ___________________________________________________________________________________________
Individual Credit
Applicant's Signature Only
Endorser, Guarantor or Surety (Co-Signer):    
    Name ______________________________    
    (Have this person complete a separate loan application. )    
Joint Credit
Joint Applicant or Co-Maker (Will be equally liable for repayment):
  Name ___________________________________  
  (Have this person complete a separate loan application.)  
Relationship to Applicant________________________________________________  
Financial Information
List all debts and financial obligations for which you are jointly or individually responsible, including rent, mortgages, credit card installments, loans, doctor bills, etc. Failure to list all debts and obligations shall be considered reason to dent credit. Please use an additional sheet if necessary.
Type of Debt Name of Creditor Monthly Payment Amount Owed
Apt. Rent   $ $
Home Mortgage   $ $
Auto Loan   $ $
Gas Credit Cards   $ $
Bank Credit Cards   $ $
Department Store Credit Cards   $ $
Bank, CU or Finance Company Loans   $ $
Medical &/0r Dental Bills   $ $
Other Debts   $ $
Amount of Loan: I hereby make application for a loan of $_____________________________
Purpose of Loan (explain fully)_____________________________________________________
  Note: If purpose of loan is to repay other debts, please identify which debts are to be repaid.  
Type of Loan Requested (check one):
Signature (new loan)
Signature (renewal or extension)
Share Secured
Secured Loan (auto, truck, boat*)
Secured Loan: Loan to be secured by:
New Auto or Truck
Used Auto or Truck
Model __________________
Serial # _______________
List All Optional Equiptment: _______________________________________  
Name & Address of Dealer or Owner:_______________________________________ Phone:__________________
Name of Insurance Co:________________________
Agent's Name:_________________
Phone: ________________
Total Stocker or Purchase Price $ ___________________________
I Hereby apply for credit with you according to the terms and conditions of such credit as I may, from time to time, request from you. You may also investigate my credit worthiness, credit history, and financial responsibility through any credit reporting agency, or by direct creditor contact, and you may directly verify my employment. I hereby direct any past, present or future employer, person, association, firm, corporation, or agency to furnish any and all information concerning me or my personal affairs, release from any liability is granted in advance. I also certify that there are no law suits pending or judgements outstanding against me other than those I have outlined in the application. I understand that any false or misleading statements in my application will cause any loan or extension or credit you grant me to be in default. You may then demand immediate payment of the balance of the loan, past due and any late charges. Section 1014, Title 18, U.S. Code Makes It a Federal Crime to Knowingly Make a Flase Statement on the Loan Application of a Federal Credit Union.


Signature Date

You Must Print, Sign, and Mail to Credit Union
or Fax to 404-845-5033


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