In order for us to process your application promptly, the information you provide on this form needs to be as accurate and complete as possible (particularly your contact information). All credit applications are subject to final approval at the offices of Central Illinois Credit Union.
WARNING: Falsification of your identity is fraud and is prosecutable by law.
Use the "Tab" key to move between fields.
The "Enter" key will (most likely prematurely) submit the form.
If you are using a screen reader or other auxiliary aid and are having problems using this form, please contact us at 217-356-9721 or toll free at 877-356-9721 and we would be happy to take your application by phone!
Identity Information
Full Name:
Birthdate (mm/dd/yyyy):
Social Security No.:
Marital Status:
Single
Married
Separated
Current Address
Street Address:
City:
State:
Zip Code:
How Long?
< 1 year
1 year
2 years
3 years
4 years
5 years
> 5 yrs
Previous Address
(if less than 5 years at current address)
Street Address:
City:
State:
Zip Code:
How Long?
< 1 year
1 year
2 years
3 years
4 years
5 years
> 5 yrs
Contact Information
Daytime Phone:
Evening Phone:
E-Mail Address:
Best Time to Call:
How would you like us to contact you?
Daytime phone
Evening phone
EMail
**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):
Individual
Joint
Loan Type:
Amount Requested:
Payment Schedule:
Payment Date:
Secured/Auto
Unsecured/Signature
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:
Auto 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?
< 1 year
1 year
2 years
3 years
4 years
5 years
> 5 yrs
Department:
Position:
Gross Monthly Income:
Previous Employer
(if less than 5 years at current job)
Employer Name:
Address:
Phone Number:
How Long?
< 1 year
1 year
2 years
3 years
4 years
5 years
> 5 yrs
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?
No
Yes - Explain to right:
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.
Not applicable
Court Order
Written Agreement
Oral Understanding
Other Financial
Are you obligated to make Alimony, Support, or Maintenance payments?
No
Yes
To whom?
/mo
Are you a co-maker, endorser, or guarantor on any loan or contract?
No
Yes
To whom?
/mo
Are there any unsatisfied judgments against you?
No
Yes
To whom?
Amount:
Have you declared bankruptcy in the last 10 years?
No
Yes
When and where was it discharged?
Outstanding Debts
Mortgage/Rent
Own Home
Rent
Name(s) on mortgage or lease:
Mortgage holder or landlord name and address:
Account Number:
Monthly Payment:
Original Amount:
Balance:
Equity Loan
Equity Line
Second Mortgage
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:
.
Click the "Accept Terms and Submit Loan Application" button below to submit.
Submission of this form implies your agreement with the terms above.
Accept Terms and Submit Loan Application
CICU Form CA-1 Version 2004 Rev. 0
Copyright 2004 Central Illinois Credit Union. All rights reserved.