Access of Lousisiana Home Page

Secure Loan Application Form

4400 Maplewood Dr. Sulphur, LA 70663
Phone: (337) 533-1808 | Fax: (337) 533-8419
   
Type Of Loan Applying For

Are you applying for individual or joint credit ?: Individual    Joint
Type:

Amount Requested: $ .00      

Term: Months


Payment Protection Coverage
Are you interested in having your loan protected: Yes No
If you answer "yes", the credit union will disclose the cost to protect your loan. The credit insurance is voluntary and does not affect your loan approval. In order for your loan to be covered, you will need to sign a separate application that explains the terms and conditions. Please contact Payment Protection Services at 800.356.2644 ext. 665.2000 with any questions.
I would like information on:
Credit Life Insurance.
Credit Disability Insurance.
Guaranteed Asset Protection (GAP). (available on vehicles ,RV, motorhomes, travel trailer, watercraft).
Mechanical Breakdown Protection (MBP). (available on vehicles only).


Applicant Information
Applicant's Name:
Account #: (if member)
Driver License #:
Social Security #:
Email:
US Citizen: Yes No
Birthdate:
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:
Home Phone #:
Cell Phone #:
Street Address:
City: State:
Zip #:
Current Address since: (MM/YY)
Rent or Own:
Monthly Housing Payment: $
Joint Applicant's Name:
Account #:
Driver License #:
Social Security #:
Email:
US Citizen: Yes No
Birthdate:
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:
Home Phone #:
Cell Phone #:
Street Address:
City: State:
Zip #:
Current Address since: (MM/YY)
Rent or Own:
Monthly Housing Payment: $


Employment Information
Applicant Employer's Name:
Employer Phone #:
Title:
Date Hired (MM/DD/YY):
Monthly Gross Income ($):
Other Income ($): per Month
Source:
Joint App. Employer's Name:
Employer Phone #:
Title:
Date Hired (MM/DD/YY):
Monthly Gross Income ($):
Other Income ($): per Month
Source:
NOTE: Alimony, child support, or separate maintenance income need not be revealed if You do not choose to have it considered as a basis for this credit request.


Debts & Assets
Child Support Payments / Alimony $
Assets:
Description: Value:
    
Description: Value:
    
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?


References (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?


Contact Method
  How would you prefer to be contacted? Home Phone Cell Phone Email
 
  Additional Comments:


Submit Application

You agree that everything stated in this application is correct to the best of your knowledge. The Credit Union is authorized to investigate your creditworthiness, employment history, and to obtain a credit report to answer questions about their credit experience with you. You understand that any false or misleading statement in your application may cause any loan or extension of credit to be in default.

Note: A current wage stub showing year-to-date information, or other income documentation will be required for loan processing. For your convenience, this information can be faxed to (337) 533-8419 after submitting your application.

By pressing the "Submit Application" button below, you agree to the above statement. You understand that we may require additional information to finalize our credit decision and your signature on additional documents prior to disbursing any credit proceeds.