Loan Application - fax to 724.694.0570

Loan Information:
Amount requested:	Co-applicant: Yes No
Loan Type:
Marital Status: Complete marital status if this loan is for: a. Joint or secured credit, or b. You reside in or rely on property located in a Community Property State. (AZ, CA, ID, LA, NM, NV, TX, WA, WI) Unmarried Married Separated This loan is not for joint or secured credit and I do not live in the states listed above.

Primary Applicant:
Member #:
Social Security #:	Birthdate:
Last Name:	First Name, M.I.:
Address 1:
Address 2:
City:	State, ZIP:
Home Phone:	E-Mail Address:
Employer:	Employer Phone:
Start Date:	Job Title:
Gross Income: Alimony, child support, or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.

Joint Applicant:
Member #:
Social Security #:	Birthdate:
Last Name:	First Name, M.I.:
Address 1:
Address 2:
City:	State, ZIP:
Home Phone:	E-Mail Address:
Employer:	Employer Phone:
Start Date:	Job Title:
Gross Income: Alimony, child support, or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.

Note:
Income verification is required; other information may be required. I certify that statements on this application are true and complete. I authorize any person, association, firm or corporation to furnish, on request of this Credit Union, information concerning me or my affairs.(Sec. 1014, Title 13, U.S. Code makes it a Federal Crime to knowingly make a false statement on this application of a Federal Credit Union.)
Primary Signature:	Date:
Joint Owner Signature:	Date: