Secure Loan Application
4400 Maplewood Dr. Sulphur, LA 70663
Phone: (337) 533-1808   •  Fax: (337) 533-8419
 
Account Number Amount Requested Type Of Loan Applying For Term
If A Member $ Months
Are you interested in having your loan protected: Yes No
If you answer “yes”, the credit union will disclose the cost to protect your loan. The credit insurance is voluntary and does not affect your loan approval. In order for your loan to be covered, you will need to sign a separate application that explains the terms and conditions. Please contact Payment Protection Services at 800.356.2644 ext. 665.2000 with any questions.
I am applying for credit as:
PRIMARY APPLICANT JOINT APPLICANT
Name: First, Middle, Last
Social Security #:

Date of Birth:

Marital Status:
What Is Your Email Address?
Home Phone #:
Cell Phone #:
Drivers License #:
State:
Mother's Maiden Name:
 
Name: First, Middle, Last
Social Security #:

Date of Birth:

Marital Status:
What Is Your Email Address?
Home Phone #:
Cell Phone #:
Drivers License #:
State:
Mother's Maiden Name:
HOME ADDRESS HOME ADDRESS
Street:
City:
State:
Zip:
Years At Address: Rent or Own:
Monthly Housing Payment: $
 
Street:
City:
State:
Zip:
Years At Address: Rent or Own:
Monthly Housing Payment:  $
EMPLOYMENT EMPLOYMENT
Current Employer:
Business Phone:
Job Title:
Date of Hire (MM/DD/YY):
(You do not need to provide information about alimony, child support, separate maintenance or other sources of income if you do not wish to have them considered as income.)
Gross Salary: $
Frequency:
Other Income: $
Frequency:
Source Of Income:
 
Current Employer:
Business Phone:
Job Title:
Date of Hire (MM/DD/YY):
(You do not need to provide information about alimony, child support, separate maintenance or other sources of income if you do not wish to have them considered as income.)
Gross Salary: $
Frequency:
Other Income: $
Frequency:
Source Of Income:
REFERENCE REFERENCE
Nearest Relative:
  Not Living With You
Relationship:
Phone:
Address:
 
Nearest Relative:
  Not Living With You
Relationship:
Phone:
Address:
OTHER INFORMATION Primary Joint
Have You Filed For Bankruptcy?
Are You A U.S. Citizen Or Permanent Resident Alien?
Are You  A Co-Maker/Endorser On Any Loan?
  If Yes, For Whom? If Yes, For Whom?
  Balance: Balance:
Do You Currently Have Any Outstanding Judgments Or Have
You Had A Debt Adjustment, Repossession, Or Property
Foreclosed In The Last 7 Years Or Are A Party To A Lawsuit?
Do You Have An Obligation To Pay Alimony/Child Support?
  If Yes, Amount
$
If Yes, Amount
$
  per per
CREDIT INSURANCE & PROTECTION
I would like information on Credit Life Insurance.
I would like information on Credit Disability Insurance.
I would like information on Guaranteed Asset Protection (GAP).  (Available on vehicles only.)
I would like information on Mechanical Breakdown Protection (MBP).  (Available on vehicles only.)
 

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.

Note: A current wage stub showing year-to-date information, or other income documentation will be required for loan processing. For your convenience, this information can be faxed to (337) 533-8419 after submitting your application.

By pressing the "Submit Application" 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.