Loan Application Type and Amount of Credit You're Requesting Is this your first loan from us? Select Yes No Amount/Credit Limit Requested: $ Approximate Time to Repay: How Many: Periods: Select Years Months Pay Period Weeks Loan Type: Select Boat Computer Debt Consolidation Line of Credit Motorcycle New Auto Recreation Vehicle Used Auto Vacation Other Security Offered: (for secured credit only) Type of Credit: Select Individual Joint Payment Protection Coverage - Check if Desired Check coverage(s) desired. The credit union will disclose the cost of this Payment Protection Coverage to you. A separate enrollment form which discloses the terms and conditions must be signed for coverage to become effective. Yes No Do you want your loan protected for you and your family if you become disabled? Yes No Do you want your loan protected for you and your family in the event of your death? Tell Us About Yourself Applicant Information: First Name: Last Name: CU Account Number: Social Sercurity Number: Driver's License#: Birth Date: (mm/dd/yyyy) Home Phone: Business Phone: Cell Phone: Email Address: Present Address: Street Address: Address Cont.: City: State: Select Alaska Alabama Arkansas Arizona California Colorado Connecticut Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana Nebraska New Hampshire New Jersey New Mexico Nevada North Carolina North Dakota New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Wisconsin West Virginia Wyoming Zip: Years at Address: Rent Own Debts Mortgage/Rent owed to: Balance (Mortgage only): Monthly Payment: Current APR % (Mortgage only): Person Responsible for Payment: Income Employer: Job Title: Time on Job: Income: Gross Net Select Annual Monthly Bi-Weekly Weekly Other Income: Other Income: (Notice: Alimony,child support or separate maintenance incom= e need not be revealed if you do not have it considered as a basis for repaying = this obligation.) Source: Select Annual Monthly Hourly Co-Applicant Information: Co-Applicatant Name and Info First Name: Last Name: CU Account Number: Social Sercurity Number: Driver's License#: Birth Date: (mm/dd/yyyy) Home Phone: Business Phone: Cell Phone: Email Address: Present Address: Street Address: Address Cont.: City: State: Select Alaska Alabama Arkansas Arizona California Colorado Connecticut Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana Nebraska New Hampshire New Jersey New Mexico Nevada North Carolina North Dakota New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Wisconsin West Virginia Wyoming Zip: Years at Address: Rent Own Debts Mortgage/Rent owed to: Balance (Mortgage only): Monthly Payment: Current APR % (Mortgage only): Person Responsible for Payment: Income Employer: Job Title: Time on Job: Income: Gross Net Select Annual Monthly Bi-Weekly Weekly Other Income: Other Income: (Notice: Alimony,child support or separate maintenance incom= e need not be revealed if you do not have it considered as a basis for repaying = this obligation.) Source: Select Annual Monthly Hourly Complete the following information if your request is for a vehicle: Type: Select Purchase Refinance N/A If purchase, do you want a: Select Pre-Approval Draft Check Payable (Fax Buyer's Order to 850-402-5334) Year of Vehicle: Make and Model: Purchase Price: Yes No I am interested in purchasing Extended Warranty/Mechanical Breakdown Protection for this loan. Yes No I am interested in purchasing GAP (Guaranteed Auto Protection) for this loan. By submitting this loan request online or by mail, you agree that the information is correct to the best of your knowledge. You also agree to notify us of any changes to your name, address or employment. You authorize the credit union to obtain credit reports in connection with this request.