TES Regional Healthcare Homepage

Secure Loan Application Form

2050 Line Avenue, Shreveport, LA 71104
Phone: (318) 222-0300 | Fax: (318) 221-6660

   
Type Of Loan Applying For

* You Must be a TES Regional Healthcare FCU Member to apply for a loan.

Type:

Amount Requested: $ .00       Collateral:

Are you applying for individual or joint credit ?: Individual    Joint

Method of Payment:
Repayment term:
Desired Payment schedule:


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.
(Ranges From .1390 To .4986 Per $100.00 Per Month)
Single Credit Disability       None
(Approx. $0.52 per $100 per month for Single/Approx. $0.91 per $100 per month for Joint)
Single Credit Life Insurance       Joint Credit Life Insurance       None


Applicant Information
Applicant's Name:
Mother's Maiden Name:
Account #:
Driver License #:
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 Address:
City: State:
Zip #:
Monthly House Payment: $ .00
Current Address since: (MM/YY)
If less than 2 yrs enter previous address:
Joint Applicant's Name:
Mother's Maiden Name:
Account #:
Driver License #:
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 Address:
City: State:
Zip #:
Monthly House Payment: $ .00
Current Address since: (MM/YY)
If less than 2 yrs enter previous address:


Employment Information
Applicant Employer's Name:
Employer Phone #:
Employer Address:
Position:
Date Hired (MM/DD/YY):
Monthly Gross Income ($):
Other Income ($): per Month
Complete if current employment is less than 2 years:
Previous Employers Name:
Yrs Employed:
Joint App. Employer's Name:
Employer Phone #:
Employer Address:
Position:
Date Hired (MM/DD/YY):
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.


Debts & Assets
Lender
Type
Balance
Min. Pmt.
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
$ .00
Assets:
Cash or Equivalent: Value:
    
Market Value of Home you Own: Value:
    
Description of Other: Value:
    
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?


References (Nearest relative not living with you)
First Name: Middle Name: Last Name: Suffix:
   Home Phone Number:
   555-555-5555
   What is their home address?
Street: City: State: Zip:
   What is the relationship?


Contact Method
  How would you prefer to be contacted? Home Phone Cell Phone Email
 
  Additional Comments:


Submit Application

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.