LOAN APPLICATION FORM
 
Name
Address
Telephone Home Mobile
Date Joined DOB
Amount of loan required Date of application
Purpose
Marital Status Dependents
Residential Status Time: Years Months
Employer's Name & Address
Telephone Work Ext
Occupation Time: Years Months
Status No. of Employees
Name Account No.
Occupation
Employer Name & Address

Income
Income
Spousal Income
  Total Income(includes all recorded income)

Borrowings/Expenses
Company Purpose Balance Monthly Amt Expense Type Monthly Amt

Summary
Unallocated Income Debt/Income Ratio (%)

Bank Details
Name Time: Years Months
Address

Declarations
I confirm that am fit to follow my normal occupation or duties  Yes  No
I/We are not indebted to any other Credit Union, Bank or loan agency either as a borrower or guarantor except as stated above, the statements herein are made for the purpose of obtaining this loan and are true to best of my knoledge and belief.
Signed (1 Date (1
Signed (2 Date (2

Repayment Protection Insurance
Initial Unprotected Repayment
I understand that this repayment is unprotected. 		Initial Protected Repayment
The benefits of Repayment Protection Insurance have been explained to me. I wish to protect my repayments.

Member
Signature

   Member
Signature		  
Breadwinner Protection
If you are not in full time employment you can still avail of RPI.
Enter the name and date of birth of the Breadwinner below and your repayments will be protected in the event of the breadwinner becoming iii or redundant.
Breadwinner
Name		 Date of Birth
Date Protection Acts 1988 & 2003: I consent to the information contained in this application form being released to the Irish League of Credit Union and Assurant General Insurance Limited and Assurant Life Limited for the purposes of Repayment Protection Insurance.
Signatures: I wish to avail of R.P.I   Yes  No
  Date: