EmailMe Form - Express Application

Individual Credit: You must complete the Applicant section about yourself and the Other section about your spouse if:
1. you live in or the property pledged as collateral is located in a community property state (AK, AZ, CA, ID, LA, NM, NV, TX, WA, WI),
2. your spouse will use the account, or
3. you are relying on your spouse's income as a basis for repayment. If you are relying on income from alimony, child support, or separate maintenance,
complete the Other section to the extent possible about the person on whose payments you are relying.

Joint Credit: Each Applicant must individually complete the appropriate section below. If Co-Borrower is spouse of the Applicant, mark the Co-Applicant
box.

Guarantor: Complete the Other section if you are a guarantor on an account/loan.

Check below to indicate the type of account(s) and type of credit for which you are applying. Married Applicants: May apply for a separate account.

LOANLINER Account/Loan:

Individual

Joint

(Including ATM/Debit Card Access to the Account if Available)

Amount Requested

$ Dollars . Cents

Purpose/Collateral

PAYMENT PROTECTION

Yes

No

If you answer "yes", the credit union will disclose the cost to protect your loan. The
protection is voluntary and does not affect your loan approval. In order for your loan to be covered, you will need to sign a separate application that explains the terms and conditions.

APPLICANT

Name

First Last

ACCOUNT NUMBER

SOCIAL SECURITY NUMBER

DRIVER'S LICENSE NUMBER

STATE

BIRTH DATE

MM / DD / YYYY

HOME PHONE

### - ### - ####

CELL PHONE

### - ### - ####

BUSINESS PHONE

### - ### - ####

Email

PRESENT ADDRESS

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

RENT OR OWN

OWN

RENT

LENGTH AT RESIDENCE

MORTGAGE/RENT OWED TO:

MORTGAGE BALANCE

$ Dollars . Cents

MONTHLY PAYMENT

$ Dollars . Cents

INTEREST RATE %

COMPLETE FOR JOINT CREDIT, SECURED CREDIT OR IF YOU LIVE IN A COMMUNITY PROPERTY STATE:

MARRIED

SEPARATED

UNMARRIED (Single - Divorced - Widowed)

EMPLOYMENT/INCOME

NAME

ADDRESS OF EMPLOYER

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

START DATE

MM / DD / YYYY

NOTICE: ALIMONY, CHILD SUPPORT, OR SEPARATE MAINTENANCE INCOME NEED NOT BE REVEALED IF YOU DO NOT CHOOSE TO HAVE IT CONSIDERED.

EMPLOYMENT INCOME

$ Dollars . Cents

Per

NET OR GROSS

NET

GROSS

OTHER INCOME

$ Dollars . Cents

Per

SOURCE

OTHER

Checkbox

CO-APPLICANT

SPOUSE

OTHER

NAME

First Last

ACCOUNT NUMBER

SOCIAL SECURITY NUMBER

DRIVER'S LICENSE NUMBER

STATE

BIRTH DATE

MM / DD / YYYY

HOME PHONE

### - ### - ####

CELL PHONE

### - ### - ####

BUSINESS PHONE

### - ### - ####

Email

PRESENT ADDRESS

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

OWN OR RENT

OWN

RENT

LENGTH AT RESIDENCE

MORTGAGE/RENT OWED TO

MORTGAGE BALANCE

$ Dollars . Cents

MONTHLY PAYMENT

$ Dollars . Cents

INTEREST RATE %

COMPLETE FOR JOINT CREDIT, SECURED CREDIT OR IF YOU LIVE IN A COMMUNITY PROPERTY STATE:

MARRIED

SEPARATED

UNMARRIED (Single - Divorced - Widowed)

EMPLOYMENT/INCOME

NAME

ADDRESS OF EMPLOYER

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

START DATE

MM / DD / YYYY

NOTICE: ALIMONY, CHILD SUPPORT, OR SEPARATE MAINTENANCE INCOME NEED NOT BE REVEALED IF YOU DO NOT CHOOSE TO HAVE IT CONSIDERED.

EMPLOYMENT INCOME

$ Dollars . Cents

Per

NET OR GROSS

NET

GROSS

OTHER INCOME

$ Dollars . Cents

Per

SOURCE

STATE LAW NOTICES

OHIO RESIDENTS ONLY: The Ohio laws make credit equally available to all creditworthy customers, and that credit reporting agencies maintain separate credit histories on each individual upon request. The Ohio Civil Rights Commission administers compliance with this law.

WISCONSIN RESIDENTS ONLY: (1) No provision of any marital property agreement, unilateral statement under Section 766.59, or court decree under Section 766.70 will adversely affect the rights of the Credit Union unless the Credit Union is furnished a copy of the agreement, statement or decree, or has actual knowledge of its terms, before the credit is granted or the account is opened. (2) Please sign if you are not applying for this account or loan with your spouse. The credit being applied for, if granted, will be incurred in the interest of the marriage or family of the undersigned.

Signature *

Clear

SIGNATURE FOR WISCONSIN RESIDENTS ONLY

DATE

MM / DD / YYYY

SIGNATURES

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. *

Clear

APPLICANT'S SIGNATURE

DATE

MM / DD / YYYY

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.

Clear

OTHER SIGNATURE

DATE

MM / DD / YYYY