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I am applying for a:
Fixed Home Equity Loan
Home Equity Line of Credit
Loan/Credit Amount Requested : $
I am applying for:   Individual credit Joint credit

Note: You must complete the Co/Joint Applicant section if the Co/Joint Applicant will use the account or you are relying on the Co/Joint Applicant's income as a basis for repayment. If you are relying on income from alimony, child support, or separate maintenance, complete the "Other Income" field, supplying as much information as possible.

(*) Indicates Required Field
Applicant Information:
*First Name:
Middle Name:
*Last Name:
*Are you a member?
Yes  No 
If yes, Account Number:
*Social Security Number:
*Date of Birth:(mm/dd/yyyy)
*Home Phone:
Cell Phone:
*Present Street Address:
*Do you:
Own  Rent  Family
Monthly Rent/Mortgage:
Employer Name:
Employer Address:
Work Phone:
*Gross Annual Income:
Start Date:
Other Income including source, how long received and amount:
Information for government monitoring purposes

The following information is requested by the Federal Government for certain types of loans related to a dwelling in order to monitor the lender’s compliance with equal credit opportunity, fair housing and home mortgage disclosure laws. You are not required to furnish this information, but are encouraged to do so. The law provides that a lender may not discriminate either on the basis of this information, or on whether you choose to furnish it. If you furnish this information, please provide both ethnicity and race. For race, you may check more than one designation. If you do not furnish ethnicity, race, or sex, under Federal regulations, this lender is required to note the information on the basis of visual observation and surname if you made this application in person. If you do not wish to furnish the information, please check the box below.
 I do not wish to furnish this information.
Ethnicity Race
 Hispanic or Latino   American Indian or Alaska Native
 Not Hispanic or Latino   Asian
Sex   Black or African American
 Male   Native Hawaiian or Pacific Islander
 Female   White

By submitting this application you promise that everything you have stated in this application is correct to the best of your knowledge. If there are any important changes you will notify us in writing immediately. You authorize the Credit Union to obtain credit reports in connection with this application for credit and for any update, increase, renewal, extension, or collection of the credit received. You understand that the Credit Union will rely on the information in this application and your credit report to make its decision. If you request, the Credit Union will tell you the name and address of any credit bureau from which it received a credit report on you. It is a crime to willfully and deliberately provide incomplete or incorrect information in this application. By submitting this application you acknowledge that you understand and agree to these terms
Please type the following characters: wTyM0o.
(Note: Characters are case sensitive.)
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