Faith Cooperative Federal Credit Union

Amount Requested *

First Payment Due Date *

1st of the month 15th of each the month

Payment Frequency *

Every Week Every 2 Weeks Monthly

Purpose of Loan *

Collateral (Secured Loan) *

INFORMATION REGARDING APPLICANT

Full Name *

Prefix First Name Middle Name Last Name Suffix

Present Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Present Address Years There *

Home Number

Please enter a valid phone number.

Cell Number

Please enter a valid phone number.

We will contact you for your Social Security Number.

Driver License *

Previous Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Previous Address Years There

Present Employer *

Position Title *

Business Phone Number *

Please enter a valid phone number.

Supervisor *

Years at Present Employer *

Previous Employer

Previous Position Tile

Previous Job Phone Number

Please enter a valid phone number.

Previous Supervisor

Years at Previous Employer

Number of Dependents (Excluding Self) *

Ages (Separate by using a comma) *

Nearest Relative not living with you *

Relationship *

Relative Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Relative Phone Number *

Please enter a valid phone number.

List 3 Personal References (Name, Full Address, Phone) *

Salary Gross Net Amount

Salary Gross Net Amount Per

Per Week Monthly Annually

Other Income

Other Income Per

Per Week Monthly Annually

Source of Other Income

*Alimony, child support, or separate maintenance income need be revealed if you do not wish to have it considered as a basis for repaying this loan.

Is any income listed likely to be reduced within the next two years?

Yes No

If "Yes", please explain

Checking Account & Routing No.

Checking Account Bank Name

Saving Account & Routing No.

Saving Account Bank Name

MARITAL STATUS: Check applicable box(es) below if this loan is for:

Type of Personal Loan

Joint Secure Credit

Where you reside or rely on property located in a Community Property State

AZ CA ID LA NM NV TX WA WIS

Applicant

Unmarried Married Separate

Other Party

Unmarried Married Separate

OUTSTANDING DEBTS (Use separate sheet if necessary: Include information about any Joint Applicant.

Outstanding Debt Applicant: Please List (Creditor, Type of Debt or Account #, Names(s) in which account is carried, Past Due (Yes/No), Present Balance, Monthly Payment, Original Debt

Outstanding Debt Other Party: Please List (Creditor, Type of Debt or Account #, Names(s) in which account is carried, Past Due (Yes/No), Present Balance, Monthly Payment, Original Debt

Are there any unsatisfied judgements against applicant and/or other party?

Yes No

If "Yes" of unsatisfied judgements by whom? and To whom?

Are there any other person obligated on any of the above loans?

Yes No

Which one of the loans and who?

Is applicant an/or other party a comaker, cosigner or guarantor on any loan?

Yes No

Who is a cosigner on which one of the loans and who?

Has the applicant/and or other party been the subject of an order for relief under The Federal Bankruptcy Code or adjudicated a bankrupt under the Bankruptcy Act in the last 10 years?

Yes No

Everything that I/we have stated in this application is correct to the best of my/our knowledge. You are authorized to check my/our credit and employment history and to answer questions about your credit experience with me/us.

Signature of Applicant

Clear

Signature of Other Party (Where applicable)

Clear