Surname (Mr/Mrs/Miss/Mssss) (required)
First Name (required)
Date of Birth (applicants must be 18 yrs or over) (required)
National Insurance Number
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 £
Employee/Payroll No. (required)
Employer Address (required)
Date Employement Commenced
—Please choose an option—Full-timePart-time
Loan Amount Requested (required) £
Loan Duration (Months/4wkly pay periods) (required)
Purpose of Loan
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 withdrawl until the loan balance is lower than the savings balance.
Please indicate how you would like to recieve the monies: —Please choose an option—Co-Operative BankBACS: Bank/BS
Account No. (required)
Sort Code (required)
Total Income Per Month (Net) (required) £
(e.g; Salary, Pension, Benefits, etc.)
Total Expenditure Per Month (required) £
(e.g; Rent, Loans, Credit Cards, Groceries, etc.)
If you are subject to any of the following, plaese tick the relevant box and provide further information:
County Court JudgementUndischarged BankruptMortgage/Loan ArrearsIndividual Voluntary ArrangementCurrently on Sick/Maternity Leave
I declare that:
To the best of my knowledge I am in good health and fit to carry out my normal occupation.
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, approprate action may be taken.
I agree to the above declaration.
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