• Application Type *
  Individual Individual with authorized user Joint

• Credit Card Type *
  Secured Unsecured

Primary Applicant

• Limit Requested *
• First Name *
• Last Name *
• Email
• Social Security Number *
• Date of Birth *
• Number of Dependents *
• Home Phone *
• Address *
• Address
• City *
• State *
  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
• Zip *
• Housing Type*
  Own Rent Other
• Monthly Rent/Mortgage Payment
• Payment Type
  Rent/Board Mortgage
• Years and Months at address *
• Previous Address
• Previous Address
• Previous City
• Previous State
  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
• Previous Zip
• Driver's License Number
• Drivers License State
  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Employment Information

• Employment Type *
  Employed Self Employed Retired Unemployed
Job Title *
Employer Name *
Employer Address *
Employer City *
Employer State *
Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Employer Zip *
Employer Phone *
Years and months at job *
Gross salary per pay period *
Pay frequency *
Monthly Bi-weekly Weekly Semi-monthly
Estimated Self Employment Income *
Self Employment Pay frequency *
Monthly Bi-weekly Weekly Semi-monthly
Estimated Retirement Income *
Retirement Pay frequency *
Monthly Bi-weekly Weekly Semi-monthly

If employed for less than 2 years at your current job:

• Previous Employer Name
• Previous Employer Address
• Previous Employer City
• Previous Employer State
  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
• Previous Employer Zip
• Previous Years and months at job

Additional Income

• Other Income Source
  Second Job Overtime Parttime Rental income Alimony Child Support Maintenance Retirement Income
• Estimated Income Amount
• Pay frequency
  Monthly Bi-weekly Weekly Semi-monthly

Additional Income

• Other Income Source
  Second Job Overtime Parttime Rental income Alimony Child Support Maintenance Retirement Income
• Estimated Income Amount
• Pay frequency
  Monthly Bi-weekly Weekly Semi-monthly

References

Reference 1

• Reference Type*
  Friend Relative
• Reference Name *
• Reference Phone *
• Reference Address
• Reference City
• Reference State
  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
• Reference Zip

Reference 2

• Reference Type *
  Friend Relative
• Reference Name *
• Reference Phone *
• Reference Address
• Reference City
• Reference State
  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
• Reference Zip

Additional Questions

• Have you ever filed bankruptcy *
  Yes No
• Are you co-maker on any loan *
  Yes No
• Monthly Payment
• Balance
• Are you liable for any child support, or maintenance payments *
  Yes No
• Monthly Payment
• What is your mother’s maiden name?*

Agreement

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 LaPorte CFCU 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. You authorize LaPorte CFCU Credit Union to verify or have re-verification of any information contained in the application at any time. You understand that LaPorte CFCU 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 federal crime to willfully and deliberately provide incomplete or incorrect information on the loan applications made to federal credit unions or state chartered credit unions insured by ASI. You understand that the use of your card will constitute acknowledgement of receipt and agreement to the terms of the credit card agreement. A condition of your account is granting us a security interest in your share accounts. By signing below you grant us a security interest in all individual and joint share and/or deposit accounts you have with us now and in the future to secure your credit card account. Shares and deposits in any account that would lose special tax treatment under state or federal law if given as security are not subject to this security interest. When you are in default we may apply the balance in these accounts to any amounts due under the credit card agreement.

• Applicant Date
• Joint Applicant Date