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Please provide all the requested information. When you have completed the form, press the Submit button to send your application. If necessary, we will contact you for additional information.

The items marked with (*) are required fields.

General Information
Will there be a co-applicant on this application? Yes No
(If Yes, the co-applicant section has the same required fields as the primary applicant.)
 
Marital Status: Complete marital status if this loan is for:
a. Joint or secured credit, or
b. You reside in or rely on property located in a Community Property State. (AZ, CA, ID, LA, NM, NV, TX, WA, WI)
Unmarried
Married
Separated
This application is not for joint or secured credit and I do not live in the states listed above.
 
*Type of Loan Requested
*Loan Amount Requested $
*Loan Term Requested months

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Primary Applicant
*Member Number
*Last Name
*First Name
Middle Name
*Social Security Number (TIN) --
*Date of Birth //
Number of Dependents
Ages of Dependents
*Home Phone Number --
Work Phone Number -- ext.
Number -- ext.
Email Address
 
Drivers License #
Drivers License State
 
Mother's Maiden Name
 

Home Address
*Address 1
Address 2
*City
*State
*Zip -
Time at Current Residence Years Months
Residence Type Own Rent Other
Monthly Payment $
 

Previous Address
Address 1
Address 2
City
State
Zip -
Time at Previous Residence Years Months
Residence Type Own Rent Other
 

Present Employer
Name
Phone Number -- ext.
Employment Status Full Time Part Time Temp
Retired Other
Job Title
Job Start Date //
Gross Salary $ Per
Other Income $ Per
Other Income Source
Alimony, child support, or separate maintenance income need not be revealed
if you do not wish to have it considered as a basis for repaying this obligation.
 

Previous Employer
Name
Phone Number -- ext.
Employment Status Full Time Part Time Temp
Retired Other
Job Title
Job Start Date //
Job End Date //
Gross Salary $ Per

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Co-Applicant
Member Number
Last Name
First Name
Middle Name
Social Security Number (TIN) --
Date of Birth //
Number of Dependents
Ages of Dependents
Home Phone Number --
Work Phone Number -- ext.
Number -- ext.
Email Address
 
Drivers License #
Drivers License State
 

Home Address
Address 1
Address 2
City
State
Zip -
Time at Current Residence Years Months
Residence Type Own Rent Other
Monthly Payment $
 

Previous Address
Address 1
Address 2
City
State
Zip -
Time at Previous Residence Years Months
Residence Type Own Rent Other
 

Present Employer
Name
Phone Number -- ext.
Employment Status Full Time Part Time Temp
Retired Other
Job Title
Job Start Date //
Gross Salary $ Per
Other Income $ Per
Other Income Source
Alimony, child support, or separate maintenance income need not be revealed
if you do not wish to have it considered as a basis for repaying this obligation.
 

Previous Employer
Name
Phone Number -- ext.
Employment Status Full Time Part Time Temp
Retired Other
Job Title
Job Start Date //
Job End Date //
Gross Salary $ Per

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References
Nearest relative Not Living With You
Last Name
First Name
Relationship
Number -- ext.
Address 1
Address 2
City
State
Zip -

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Debts/Monthly Payments
List all other debts (for example, auto loans, credit cards, second mortgage, home assoc. dues, alimony, child support, child care, medical utilities, auto insurance, IRS liabilities, etc.) Please use a separate line for each credit card and auto loan.
Debts
Monthly Payments
Credit Card $
$
$
$
$
$
$
$
$
$
$

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Additional Information
How would you prefer to be contacted?
Home Phone
Work Phone
Cell Phone
Email Address
Other
Special Instructions/Comments
 

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Income verification is required; other information may be required.

I certify that statements on this application are true and complete. I authorize any person, association, firm or corporation to furnish, on request of this Financial Institution, information concerning me or my affairs. (Sec. 1014, Title 18, U.S. Code makes it a Federal Crime to knowingly make a false statement on this application.)

Please enter the word from the following graphic into the box below:


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Hours of Operation
9 a.m. to 5 p.m. Monday through Thursday • 9 a.m. to 6 p.m. Friday • 9 a.m. to 1 p.m. Saturday
5025 E. Main Street • Columbus, Ohio 43213 • Phone: 614-866-5025 • Fax: 614-866-0120
Routing and Transit Number: 244078018
Privacy Policy/Terms and Conditions

Your deposits are insured up to $500,000.
This institution is not federally insured, and if the institution fails, the Federal Government does not guarantee
that the depositors will get back their money.
MEMBERS’ ACCOUNTS ARE NOT INSURED OR GUARANTEED BY ANY GOVERNMENT OR GOVERNMENT SPONSORED AGENCY.

 ASI

 

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