Secure Loan Application
1512 Coonskin Drive, Charleston, WV  25311
Phone: (304) 342-2422 • Fax: (304) 342-3364


1. Type Of Loan Applying For

New Auto Loan
Used Auto Loan

Recreational Vehicle (Boat, Camper, ATV, Motorcyle)
Personal Loan   Purpose:
Requested Amount: $ .00 For A Period Of Months
Year: Make: Model: Book Value:
VIN #: Mileage: Trim:

2. Payment Protection Coverage
Are you interested in having your loan protected? Yes No
If you answer "yes", then the credit union will disclose the cost of this voluntary payment protection to you. A separate election which discloses the terms and conditions must be signed for protection to be effective.

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.

Single Credit Disability
Single Credit Life Insurance
GAP Insurance
Mechanical Repair Coverage

3. Applicant Information
Applicant:

US Citizen Yes No
Name:
Account #:
Social Security #:
Drivers License #: State:
Birthdate (MM/DD/YY):
Please indicate your marital status if you are applying for joint credit, secured credit or if you live in a community property state:
Married Separated Unmarried (single-divorced-widowed)
Home Phone #:
Cell Phone #:
Present Address:
Street:
City:
State & Zip:
Current Address since: (MM/YY)
If less than 3 yrs enter previous address:

Dependents:   Ages:

Joint Applicant:

US Citizen Yes No
Name:
Account #:
Social Security #:
Drivers License #: State:
Birthdate (MM/DD/YY):
Please indicate your marital status if you are applying for joint credit, secured credit or if you live in a community property state:
Married Separated Unmarried (single-divorced-widowed)
Home Phone #:
Cell Phone #:
Present Address:
Street:
City:
State & Zip:
Current Address since: (MM/YY)
If less than 3 yrs enter previous address:

Dependents:    Ages:


4. Employment Information
Applicant:

Employer Name:

Employer Phone #:
Employer Address:


Department:
Supervisor:
Position:
Date Hired (MM/DD/YY):
Monthly Gross Income $
Other Income: $ per Month
Source:

Federal Technician
Grade: Step:

AGR
Rank over Years

Complete if current employment is less than 2 years:
Previous Employers Name:

Yrs Employed:

Joint Applicant:

Employer Name:

Employer Phone #:
Employer Address:


Department:
Supervisor:
Position:
Date Hired (MM/DD/YY):
Monthly Gross Income $
Other Income: $ per Month
Source:

Complete if current employment is less than 2 years:
Previous Employers Name:

Yrs Employed:

Is any income listed likely to be reduced before this loan is paid off? Yes No Is any income listed likely to be reduced before this loan is paid off? Yes No
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.

5. 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
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?
Are you a U.S. citizen or permanent resident alien?

6. References
Nearest Relative NOT Living with you:
  Name:
First: Middle: Last: Suffix:
   Home Phone Number:
555-555-5555
   What is their home address?
Street: City: State: Zip:
   What is the relationship?

Comments:

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.     

Submit Application