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Identity Information
Full Name: Birthdate (mm/dd/yyyy): Social Security No.: Marital Status:
Current Address  
Street Address: City: State: Zip Code: How Long?
Previous Address (if less than 5 years at current address)
Street Address: City: State: Zip Code: How Long?
Contact Information  
Daytime Phone: Evening Phone: E-Mail Address: Best Time to Call:
How would you like us to contact you? **Primary applicant only.
Name and address of nearest relative not living with you:** Relationship:**
Credit Requested (Note: For joint credit applications, both the primary borrower and co-borrower must submit a credit application)
Application Type: Name of primary borrower (joint application only): Name of co-borrower (joint application only):
Loan Type: Amount Requested: Payment Schedule: Payment Date:
Loan Purpose:
Collateral Pledged (Secured loans only)
Type of Collateral Pledged (e.g. Auto, Shares, RV, Motorcycle, Boat):
Current Lienholder (If this loan is a refinance of another loan for which the same collateral is pledged.)
Name: Address: Account Number: Payoff Amount:
Description  
Make: Model: Year: Vehicle Identification Number (if known):
Names and Addresses of All Co-Owners: Other Description or Comments:
Employment Information
Employer Name: Address: Phone Number: How Long?
Department: Position: Gross Monthly Income:
Previous Employer (if less than 5 years at current job)
Employer Name: Address: Phone Number: How Long?
Additional Income
Amount Per Month Source of Additional Income Is any income listed in this Section likely to be reduced before the credit request is paid off?
Alimony, child support, or separate maintenance received under:* *Alimony, Child Support or Separate Maintenance income need not be revealed if you do not wish to have it considered as a basis for repayment.
Other Financial
Are you obligated to make Alimony, Support, or Maintenance payments? To whom? /mo
Are you a co-maker, endorser, or guarantor on any loan or contract? To whom? /mo
Are there any unsatisfied judgments against you? To whom? Amount:
Have you declared bankruptcy in the last 10 years? When and where was it discharged?
 
Outstanding Debts
Mortgage/Rent  
Name(s) on mortgage or lease: Mortgage holder or landlord name and address:
Account Number: Monthly Payment: Original Amount: Balance:
Equity Loan  
Name(s) on loan: Creditor name and address:
Account Number: Monthly Payment: Original Amount: Balance:
Auto Loan  
Vehicle Description: Name(s) on loan: Creditor name and address:
Account Number: Monthly Payment: Original Amount: Balance:
Other Credit Obligation  
Loan Type: Name(s) on account: Creditor name and address:
Account Number: Monthly Payment: Original Amount: Balance: Collateral (if any):
Other Credit Obligation  
Loan Type: Name(s) on account: Creditor name and address:
Account Number: Monthly Payment: Original Amount: Balance: Collateral (if any):
Other Credit Obligation  
Loan Type: Name(s) on account: Creditor name and address:
Account Number: Monthly Payment: Original Amount: Balance: Collateral (if any):
Other Credit Obligation  
Loan Type: Name(s) on account: Creditor name and address:
Account Number: Monthly Payment: Original Amount: Balance: Collateral (if any):
Other Credit Obligation  
Loan Type: Name(s) on account: Creditor name and address:
Account Number: Monthly Payment: Original Amount: Balance: Collateral (if any):
Other Credit Obligation  
Loan Type: Name(s) on account: Creditor name and address:
Account Number: Monthly Payment: Original Amount: Balance: Collateral (if any):
 
By submitting this application, I certify that everything I have stated in this application and on any attachments is correct. You may keep this application record whether or not it is approved. By electronically submitting this application form, I authorize you to check my credit and employment history and to answer questions others may ask you about my credit record with you. I understand that I must update credit information at your request if my financial condition changes.
Signature: Date:  
 
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CICU Form CA-1 Version 2004 Rev. 0 Copyright 2004 Central Illinois Credit Union. All rights reserved.