Twin States Federal Credit Union -- Secure Loan Application

	59 Yorkville Park Square, Columbus MS 39702 Phone: (662) 327-7666
	*Secure Loan Application*

Account Number - (You must be a member to apply)	Amount Requested	Type Of Loan Applying For	Term
	$		Months

PRIMARY APPLICANT

JOINT APPLICANT

Name: First, Middle, Last

SSN:	Date of Birth:
Drivers License Number:

SSN:	Date of Birth:
Drivers License Number:

What Is Your Email Address?

Home Phone Number:	Cell Phone Number:
I Can Be Best Reached Via:

Home Phone Number:	Cell Phone Number:
I Can Be Best Reached Via:

What Is Your Home Address?

Street:	City:

What Is Your Home Address?

Street:	City:

State:

Zip:

State:

Zip:

Monthly Housing Payment: $

Current Employer:

Business Phone:

Current Employer:

Business Phone:

Length Of Employment:

Gross Salary: $ Frequency:

Other Income: $ Frequency:

Source Of Income:

OTHER INFORMATION

(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.)

Would you like to purchase Credit Life Insurance? Single Credit Life (Only Available for Applicant) Joint Credit Life None

Would you like to purchase Single Credit Disability Insurance? Yes None

Would you like to purchase GAP Insurance? Yes None

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, Then For Whom?

Balance: $

Do You Currently Have Any Outstanding Judgements Or Have You Had A Debt Adjustment, Repossession, Or Property Foreclosed In The Last 7 Years Or Are A Party To A Lawsuit?

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. Security on one loan is security on any monies owed to the Credit Union.

PLEASE MAIL, FAX, OR BRING INTO TO OUR OFFICE YOUR MOST RECENT PAY CHECK STUB.

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.