Healthcare Services Home Page

Secure Loan & Visa Application

 946 East Third Street, Chattanooga, TN 37403
Phone: (423) 242-4728 • Fax: (423) 242-1940



Type Of Loan Applying For
New or Used Vehicle Loan
Share Secured
Credit Builder
 Personal Signature Loan
Visa Credit Card (Visa Disclosure)
Other:
Purpose of loan :
Requested Amount : $ .00



Payment Protection Coverage
Check coverage(s) desired. The Credit Union will disclose the cost of this voluntary insurance to you. A separate enrollment form which discloses the terms and conditions must be signed for coverage to become effective.
Single Credit Life Insurance                              Joint Credit Life Insurance                              None
Applicant Information
Applicant's Name:
Account #:
Social Security #:
US Citizen: Yes No
Birthdate (MM/DD/YY):
Driver's License:
Please indicate your marital status if you are applying for joint credit, secured credit or if you live in a community property state:
Marital Status:
Email Address :
Number of Dependants :
Ages of Dependants :
Home Phone #:
Mobile Phone #:
Address :
City : State:
Zip #:
Current Address since: (MM/YY)
Rent     Own     Payment:
If less than 3 yrs enter previous address:
Number of months at residence:
Joint Applicant's Name:
Is Joint Applicant your spouse? Yes No
Account #:
Social Security #:
US Citizen: Yes No
Birthdate (MM/DD/YY):
Driver's License:
Please indicate your marital status if you are applying for joint credit, secured credit or if you live in a community property state:
Marital Status:
Email Address :
Number of Dependants :
Ages of Dependants :
Home Phone #:
Mobile Phone #:
Address :
City : State:
Zip #:
Current Address since: (MM/YY)
Rent     Own     Payment:
If less than 3 yrs enter previous address:
Number of months at residence:


Employment Information
Applicant Employer's Name:
Employer Phone #:
Employer Address :
Position:
Status: Full Time Part Time
Date Hired (MM/DD/YY):
Hourly Wage / Month Salary ($):
Other Income ($): per Month
Other Income Source :
Prev. Employers Name:
Prev. Job Start Date:
Prev. Job End Date:
Joint App. Employer's Name:
Employer Phone #:
Employer Address :
Position:
Status: Full Time Part Time
Date Hired (MM/DD/YY):
Hourly Wage / Month Salary ($):
Other Income ($): per Month
Other Income Source :
Prev. Employers Name:
Prev. Job Start Date:
Prev. Job End Date:



Personal Financial Profile
(Please answer questions below)
Assets
Estimated Value
Liabilities
Dollar Amount Owed
Cash in Credit Unions / Banks:
$ .00
 Loans Owed to HSCU:
$ .00
Stocks & Bonds:
$ .00
 Credit Cards:
$ .00
Retirement:
$ .00
  
$ .00
Vehicle Year: Make: Vehicle Loan: $ .00
Vehicle Year: Make: Vehicle Loan: $ .00
Home:
$ .00
 Mortgage:
$ .00
Other Real Estate:
$ .00
 Other Real Estate Loans:
$ .00
 
$ .00
  
$ .00
$ .00
$ .00
$ .00 $ .00
$ .00 $ .00
       
Total Assets $ .00 Total Loan Balances $ .00
    (Total Assets - Total Loan Balances) =
Net Worth		 $ .00
These questions must be answered.
Have you ever filed for bankruptcy or had debt adjustment under Chapter 13?
   Are you a party in a lawsuit?
   Have you ever had property foreclosed or repossesion in the last 7 years?
   Is your income likely to decline in the next two years?
Are you co-maker/endorser on any loan not listed above?
   If yes then for whom?
   If yes then to whom?
Are you a U.S. citizen or permanent resident alien?

Applicant Reference (Nearest relative not living with you)
First Name: Middle Name: Last Name: Suffix:
   Home Phone Number:
   555-555-5555
   What is their home address?
Street: City: State: Zip:
   What is the relationship?

 
Co-applicant Reference (Nearest relative not living with you)
First Name: Middle Name: Last Name: Suffix:
   Home Phone Number:
   555-555-5555
   What is their home address?
Street: City: State: Zip:
   What is the relationship?


Submit Application

I/We understand that credit union membership is required to fully process this loan application and further documentation / signatures may be required. By submitting this form with your electronic signature(s), you agree that everything stated in this application is correct to the best of your knowledge and grant permission to Healthcare Services Credit Union to perform the following. HSCU is authorized to validate your information, investigate your creditworthiness, employment history, and obtain a credit report. You understand that any false or misleading statement in your application may cause any loan or extension of credit to be in default. You authorize us to accept your facsimile signatures on this application and agree that your facsimile signature will have the same legal force and effect as your original signature. You assume any risk that may be associated with permitting us to accept your facsimile signature. HSCU may keep this application whether or not it is approved.

If you are applying for a credit card, you understand that the use of your card will constitute acknowledgement of receipt and agreement to the terms of the credit card agreement and disclosures. 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. When you are in default, you authorize us to apply the balance in these accounts to any amounts due. Shares and deposits in an Individual Retirements Account, and any other account that would lose special tax treatment under state or federal law if given as security, are not subject to the security interest you have given in your shares and deposits.

By pressing the "Submit Application" button below, you agree to the above statement.  

To avoid delays in processing your request please provide us with the best method and time to contact. Best method of contact:
 Home Phone      Mobile Phone      Work Phone              What time of day is best to call:


Date:
 Primary Signature:
 Joint Signature:
Enter The Security Code Displayed In The Box Below:
[858932]