Loan Application Form

Title (Mr/Mrs/Miss/Ms) (required)

First Name (required)

Surname (required)

Membership No.

Home Address (required)

Post Code (required)

Home Tel

Work Tel

Mobile Tel

Email

Date of Birth (applicants must be 18 yrs or over) (required)

No. of Dependants (required)

Time at Current Address (required)

(If less than 3 years, please provide details of your previous address)

Type of Accommodation (required) —Please choose an option—OwnerTenantWith ParentsLodger

If Owned, Approx Value £

If Mortgaged, Approx Mortgage £

Mortgage Provider

Term Remaining

Employee/Payroll No.

Pension No.

Employer (required)

Dept. (required)

Employer Address (required)

Post Code

Date Employement Commenced

Employment Time —Please choose an option—Full-timePart-time

Loan Amount Requested (required) £

Loan Duration (Months/4wkly pay periods) (required)

Purpose of Loan (required)

Estimated Total Cost (required) £

I wish to continue to save (required) £

per month/4 weeks

You must continue to save a minimum of £10 per month/4 weeks in your main share account whilst repaying your loan. The savings in the share account will not be available for withdrawal until the loan balance is lower than the savings balance.

Account Name

Account No. (required)

Sort Code (required)

Please complete the following section to the best of your knowledge.

Income (£ per month - Net)

Salary/Wages:

Pension:

Benefits:

Other: (please specify)

Total Income: (required)

Expenditure (£ per month)

Rent/Mortgage:

Outstanding Balance:
Value of Assets:

Council Tax:

Electricity:

Gas:

Telephone:

Groceries:

Catalogues:

Outstanding Balance:

Credit Cards:

Outstanding Balance:

Hire Purchases:

Outstanding Balance:

Car Loan:

Outstanding Balance:

Other Loans:

Outstanding Balance:

Travel:

Clothing:

Savings/Investments:

Value of Assets:

Home Insurance:

Car Insurance:

Other: (please specify)

Outstanding Balance:
Value of Assets:

Total Expenditure: (required)

If you are subject to any of the following, please tick the relevant box and provide further information:

County Court JudgementUndischarged BankruptMortgage/Loan ArrearsIndividual Voluntary ArrangementCurrently on Sick/Maternity Leave

I declare that:

• I am not indebted to any other Credit Union, bank or loan agency as a borrower, guarantor or surety except as stated above.

• Neither I nor any company which I am a shareholder or director is the subject of any bankruptcy or insolvency proceeding or interim administration order either now or pending or threatened pursuant to the Insolvency Act 1986.

• I have not served or been served notice of termination of my employment.

I further declare the information given on this form is accurate and correct. I understand that the provision of false information is fraud and that in the event I am found to have deliberately falsified information, appropriate action may be taken.

I agree to the above declaration.