Jax Glidco Employees FCU

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MEMBER/BORROWER
First Name
Middle Initial
Last Name
Address
City
State
Zip Code
Home Phone
Date of Birth
Employer
Work Phone
Date of Hire
Hourly Wage
Monthly Gross Income

CO-BORROWER/CO-SIGNER
First Name
Middle Initial
Last Name
Address
City
State
Zip Code
Home Phone
Date of Birth
Employer
Work Phone
Date of Hire
Hourly Wage
Monthly Gross Income

OTHER INCOME

Source Amount
Total Monthly Income

Amount Requested
Purpose
Collateral Description
Term of loan	months

Marital status

Income from alimony/child or spousal support payments need not be revealed unless you want the credit union to consider them as a basis for repayment of debt.

Notice to Wisconsin Residents
No provision of a marital property agreement, a unilateral statement under Wis. Stat. SEc. 766.59 or a court decree under Wis. Stat. Sec. 766.70 adversely affects the interests of the credit union unless prior to the time the credit is extended, the credit union is furnished with a copy of the agreement, statement or decree, or has actual knowledge of the adverse provision when the obligation to the credit union is incurred.

Have you ever declared bankruptcy?NoYes
Year Reason

Monthly rent or mortgage amount

Rent Mortgage

Please note: Income verification and other information may be required.

I/We agree that, by submitting this application, I/we certify that the foregoing information has been supplied truthfully, accurately and voluntarily, and therefore authorize this credit union to investigate our creditworthiness, credit history, and financial responsibility through any credit bureau or by any other reasonable means. If I/we am/are married, applying for individual credit, and living in a community property state, I/we certify that the credit being applied for, if granted, will be incurred in the interest of the marriage or family. If this statement applies, we are required by Wisconsin law to notify your spouse by mail if your loan is granted.