Loan Application Form – Agricola Credit Union

Personal Data

Member Number *

Branch *

Name *

Street Address *

Proof of Address *

Mailing Address

ID *

Email Address

Home Phone

Work Phone

Cell Phone

Date of Birth

Marial Status *

Dependents

Reference 1 Name *

Reference 1 Address *

Reference 1 Phone

Reference 1 Relationship *

Reference 2 Name *

Reference 2 Address *

Reference 2 Phone

Reference 2 Relationship *

Purpose of Loan

Loan Purpose *

Loan Type

Loan Term

Loan Amount

TTD

Employment Details

Employer Name *

Employer Address *

Payslip *

Employment Status

Payroll paid at

Position

Tenure in years

Assets

Shares

Deposit Accounts

Deposit Accounts 2

Unit Trust Shares

Fixed Deposits

Stock/Other Shares

Annuities

Insurance C.S.V.

Real Estate

Vehicle

Furniture/Fixtures

Other

Assets

Liabilities

C.U. Loan1

TTD

C.U. Loan2

TTD

Bank Loan

TTD

Insurances

TTD

Policy Loan

TTD

Tax (Land/Building, etc.)

TTD

Mortgage/Rent

TTD

Other

TTD

Liabilities

Income Information

Monthly Salary

TTD

Spouse's Income

TTD

Other Income

TTD

Total Net Income

$

Expenses

Hire Purchase

TTD

Utility Bills

TTD

Food

TTD

School Fees/Expenses

TTD

Car/Travelling Expenses

TTD

Total Debt/Payments

I/We warrant and confirm the information given herein is true and correct and I/we understand it is being used to determine my/our credit responsibility. I/We further confirm that no information which might affect the Credit Union's decision to make a loan has been withheld. I/We hereby authorize and consent to the Credit Union receiving and exchanging any financial and other information which it may have in its possession about me/us with any subsidiaries, agents, third party assignees, other financial institutions, Credit Bureaus or other person or Corporation or with whom I/We may have or propose to have financial dealings from time to time. I/We indemnify the Credit Union against any loss, claims, damages, liabilities, actions and proceedings, legal or other expense which may directly and reasonably incurred as a consequence of the disclosure of information. My/Our deposit account may be charged with the monthly payments as they mature and I/We agree to pay your customary assessment for any notices of overdue installments. *YES

Save as Draft