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Consumer Healthcare Federal Credit Union Loan Application Form

Applicant Information:
Name:
Account Number:
E-mail address:
Social Security #:
Driver's License Number:
Home Phone:
Cell Phone:
Birth Date:
Current Address:  
Street:
City:
State:
Zip:
How many years have you lived at your current address?
Do you rent or own? Rent Own
Previous Address:  
Street:
City:
State:
Zip:
How many years did you live at this address?
Did you rent or own? Rent Own
Current Employer:
Employer's Phone:
Date Started:
Job Position/Title:
Est. Monthly Salary: $
Are you a U.S. Citizen or permanent resident alien? Yes No
Do you currently have any outstanding judgements or have you filed for bankruptcy, had a debt adjustment plan confirmed under chapter 13, had a property forclosed upon or repossessed in the last 7 years or been party in a lawsuit? Yes No
Are you a co-maker, co-signer, or guarantor on any loan not listed below? If yes, list for whom and to whom below. Yes No
For: To:
Reference 1:  
Name: Phone:
Address: City, State, Zip:
Reference 2:  
Name: Phone:
Address: City, State, Zip:
   
Co-Applicant Information:
Name:
Cu Account #(If any):
Social Security #:
Phone Number:
Birth Date:
Current Address:  
Street:
City:
State:
Zip:
How many years have you lived at your current address?
Do you rent or own? Rent Own
Previous Address:  
Street:
City:
State:
Zip:
How many years did you live at this address?
Did you rent or own? Rent Own
Current Employer:
Employer's Phone:
Date Started:
Job Position/Title:
Est. Monthly Salary: $
Are you a U.S. Citizen or permanent resident alien? Yes No
Do you currently have any outstanding judgements or have you filed for bankruptcy, had a debt adjustment plan confirmed under chapter 13, had a property forclosed upon or repossessed in the last 7 years or been party in a lawsuit? Yes No
Are you a co-maker, co-signer, or guarantor on any loan not listed below? If yes, list for whom and to whom below. Yes No
For: To:
   
Loan Information:
Type of Loan:
How many months to pay this back?
Amount Requested: $
Would you like credit disability insurance on your loan? No Yes
Would you like credit life insurance on your loan? No Yes
The credit union will disclose the cost of this voluntary insurance to you. A seperate insurance election which disloses the terms and conditions must be signed for coverage to become effective.  
If a vehicle loan, please describe the year, make, model, VIN number, and the dealership you are purchasing from. For all other types of loans please describe the purpose for the loan.
   
Debts:
Debtor Current Balance Monthly Payment Consolidate Into New Loan?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
If you have any other information you would like us to consider, or any comments or suggestions, please enter them  here:
By submiting this form, you hereby grant permission to the Credit Union to gather any relevant data on you necessary to complete your Loan application, such as credit reports. Proof of income in the form of 2 recent paystubs must be faxed to (412) 424-6054. Members must maintain a minimum balance of $200.00 in their share account until the loan is paid off.
 

Identity Verification Notice

On October 26, 2001, President Bush signed into law the USA Patriot Act. The purpose of this law is to help protect you, your family and our country from terrorism by preventing terrorist financing. We want you to know that section 326 of this Act requires our credit union to verify the identity of all new credit union members. We must also verify the identity of members and nonmembers added as signatories to and have access to new or existing deposit account and loans. We must also retain copies of documents used to verify your identity.

If you are an existing member who joined the credit union before the USA Patriot Act rules became effective we may also need to verify and retain copies of any documents used to verify your identity when you request a new deposit account, apply for a loan or are added as a signatory to a new or existing deposit or loan account.

We ask for your understanding as we work to support these efforts to maintain the security of your funds and our country. Please speak with a credit union staff member if you have any questions or concerns about our identification policies.

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