Southcoast Health System Federal Credit Union

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Please print this form, fill it out and fax, along with two paystubs for each applicant, to: (508) 961-5297
APPLICATION
Loan Information:
 Do you want Life/Disability Insurance? Yes No  Payroll deduction or monthly?
 Amount requested:                                       Term:  Co-applicant: Yes No
 Loan Type:
 Marital Status: Complete marital status if this loan is joint.   Unmarried Married Separated
 
 Primary Applicant:
 Member #:  Type of Loan:
 Social Security #:  Birthdate:
 Last Name:  First Name, M.I.:
 Address:
 City:  State, ZIP:
 Home Phone:  E-Mail Address:
 Employer:  Job Title:
 Start Date:  Employer Phone:
 Relative Name (Not living with you):  Relative Phone:
 Relative Address:
 Joint Applicant:
 Member #:
 Social Security #:  Birthdate:
 Last Name:  First Name, M.I.:
 Address:
 City:  State, ZIP:
 Home Phone:  E-Mail Address:
 Employer:  Job Title:
 Start Date:  Employer Phone:
 Relative Name (Not living with you):  Relative Phone:
 Relative Address:
 Income:
 Monthly Gross Wages/Income*  $  Monthly Gross Wages/Income*  $
 Other Income (describe)  $  Other Income(describe)  $
 Other Income (describe)  $  Other Income (describe)  $
 (1)Total Monthly Income  $  (2)Total Monthly Income  $
   $  (1 and 2)Total Monthly Income  $
       
       
 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.)
 Debts:
 Debt Monthly Payment   Debt Monthly Payment 
 Rent/Mortgage  $    $
   $    $
   $    $
   $    $
   $    $
       
       
AGREEMENT: For the purpose of this section the words, "I", "Me" and "My" mean each and all of those who sign this application. I hereby apply for credit as indicated on the reverse side of this form and verify that all information given is true and complete to the best of my knowledge. I understand that you will rely on this information in determining whether or not to extend credit and that failure to list all of my debts constitutes a materially false financial statement. As part of the procedure for processing this credit application, a consumer report containing information bearing on my credit-worthiness and personal characteristics may be requested from a consumer reporting agency, and by signing below authorize you to obtain such a report. I have the right to request that you inform em as to whether or not you actually requested such a consumer report in connection with this application and, if such a report was so requested, to be informed of the name and address of the consumer to be informed of the name and adddress of the soncumer reporting agency that furnished the report. You may also request or utilize subsequent consumer reports in connection with an update, renewal, or extension of the credit applied for without additional notice. I agree that this account will be governed by an agreement which will be provided to me at the time my application is approved. If my application is approved, I acknowledge your right to withdraw that approval at any time prior to the closing of my loan if there is an adverse change in any information contained in this application, including a loss of employment or other adverse change in my financial condition. Please Note: This application must be filled out completely or it cannot be submitted for review.
 Applicant Signature:  Date:        
 Joint Applicant Signature:  Date:        
 Loan Officer Signature:  Date:        
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Southcoast Health System Federal Credit Union
101 Page Street
New Bedford, MA 02740
© 2001 Pat Saladino, Webmaster - SHSFCU@aol.com