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MEMBER LOAN APPLICATION

Applicant Information
First Name: Middle Initial: Last Name:

Social Security Number: Date of Birth: Number of Dependents: Driver's License Number:

PO/Street Address: Apt. No.: Own Monthly Payment:


Rent

City: State: Zip: How Long: Home Phone:

Former Address if above address is less than 7 years: City: State: Zip: How Long:

Employment
Current Employer: How Long: Position/Title: Monthly
Salary:

Address: City: State: Zip: Work Phone:

Previous Employer/Address if current employer under 5 years: How Long:

Co-Applicant Information
First Name: Middle Initial: Last Name:

Social Security Number: Date of Birth: Monthly Salary: Work Phone:

Employer: How Long: Position/Title:

Address: City: State: Zip:

Additional Income
Additional Source of Income: Monthly Amount:

Additional Source of Income: Monthly Amount:

(Continued)

10/99 SMS-008
References List Banks, Stores, Charge Cards, etc.
Account With Address Account Number Balance Owing Monthly Payment

Checking

Savings

Mortgage

Auto Loan
Credit
Acct. #1
Credit
Acct. #2
Credit
Acct. #3

Loan Amount / Purpose


Amount: Purpose:

The above information is correct and is given for the purpose of obtaining credit. You are authorized
to verify this information and to obtain additional information in reviewing this credit request.
Both Signatures are Required for a Joint Application

_______________________________________ ______________________________________ _____________


Applicant Signature Joint Applicant Signature Date

FOR SSVEC USE ONLY

Date application received: _____________ Taken by: ________________________________________

Account Number: _________________ Premise Number: _______________

Service established date: __________Cooperative Credit Rating: _____________CDSW Rating: ____________

Term Length (in months): ___________ Payment Due: 1st or 15th

Has the applicant established credit as defined in the Cooperative’s rules? YES NO

Other information or recommendations: _________________________________________________________

__________________________________________________________________________________________

A loan of not more than __________________ will be available to this member.

____________________________________________________________ ______________
Cooperative Representative Date

10/99 SMS-008

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