Applicant Information

Applicant's Name ___________________________________ SSN_______________________  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 Street_______________________________________    City________________________________________    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) Unmarried Married Separated 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 Co-Maker Secured Loan (auto, truck, boat*) Secured Loan: Loan to be secured by: New Auto or Truck Used Auto or Truck Boat Other Make_______________________ Model __________________ Year_____________ 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 $ ___________________________ * ITEMIZED BILL OF SALE MUST BE ATTACHED

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