Type and Amount of Credit You're Requesting

• Is this your first loan from us? *
  Yes No
• Amount/Credit Limit Requested *
  $
• Approximate Time to Repay *
  36 Months 48 Months 60 Months 72 Months

  (Must be greater than $20,000 for 72 month term.)

• Loan Purpose *
  Boat Computer Debt Consolidation Line of Credit Motorcycle New Auto Recreation Vehicle Used Auto Vacation Other Credit Card
Security Offered

(for secured credit only, not applicable to credit cards)

• Application Type *
  Individual Joint

Payment Protection Coverage

Select if desired

Find out more about Payment Protection Insurance and why it's a better consumer value when offered through your credit union.

Check coverage(s) desired. We will disclose the cost of this Payment Protection Insurance - Credit Disability and Credit Life - to you. A separate enrollment form which discloses the terms and conditions must be signed for coverage to become effective.

• Do you want your loan protected for you and your family if you become disabled?
  Yes No

Applicant Information

• Name *
• CU Account # *
• Social Security # *
• Please indicate your marital status if you are applying for Joint Credit, secured credit or if you live in a community property state:
  Married Separated Unmarried (Single - Divorced - Widowed)
• 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
• Date of Birth *
• Home Phone *
• Business Phone *
• Email *
• Present 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 *
• Years at address *
• Housing Type *
  Rent Own
• Personal Reference
• Reference Phone
• Mortgage/Rent Owed to
• Mortgage Balance
• Monthly payment
• Cuurent APR %
• Person responsible for payment
• Person responsible for payment
• Debt
• Balance
• Monthly Payment
• Debt
• Balance
• Monthly Payment
• Debt
• Balance
• Monthly Payment
• Debt
• Balance
• Monthly Payment
• Please list any other debts

Joint Applicant

Name *

CU Account # *

Social Security # *

Please indicate your marital status if you are applying for Joint Credit, secured credit or if you live in a community property state:

Married Separated Unmarried (Single - Divorced - Widowed)

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

Date of Birth *

Home Phone *

Business Phone *

Email *

Present 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 *

Years at address *

Housing Type *

Rent Own

Personal Reference

Reference Phone

Mortgage/Rent Owed to

Mortgage Balance

Monthly payment

Cuurent APR %

Person responsible for payment

Person responsible for payment

Debt

Balance

Monthly Payment

Debt

Balance

Monthly Payment

Debt

Balance

Monthly Payment

Debt

Balance

Monthly Payment

Please list any other debts

Employment Information

• Employer *
• How long?
• Gross Income
• Pay frequency *
  Annual Monthly Bi-weekly Weekly
• Other Income (Notice: Alimony, child support or separate maintenance income need not be revealed if you do not have it considered as a basis for repaying this obligation.)
• Other Income source
• Other Income Pay frequency
  Annual Monthly Hourly

Joint Applicant

Employer *

How long?

Gross Income

Pay frequency *

Annual Monthly Bi-weekly Weekly

Other Income (Notice: Alimony, child support or separate maintenance income need not be revealed if you do not have it considered as a basis for repaying this obligation.)

Other Income source

Other Income Pay frequency

Annual Monthly Hourly

Credit Card Disclosures

CREDIT CARD DISCLOSURE	GENY	CLASSIC	PLATINUM
Annual Percentage Rate for Purchases	7.95%	11.95%	9.95%
Other APRs Cash Advance APR Balance Transfer APR	7.95%	11.95%	9.95%
Introductory Offer for 6 Billing Cycles:	N/A	7.95%	7.95%
Grace Period for Repayment of the Balance for Purchases	25 days	25 days	25 days
Grace Period for Cash Advances	NONE	NONE	NONE
Method of Computing the Balance for Purchases	AVERAGE DAILY BALANCES (INCLUDING NEW PURCHASES)
Annual Fees	NONE	NONE	NONE
Minimum Finance Charge	NONE	NONE	NONE
Transaction Fee for Purchases	NONE	NONE	NONE
Transaction Fee for Cash Advances	NONE	NONE	NONE
Balance Transfer Fee	NONE	NONE	NONE
Late Payment Fee	$25.00	$25.00	$25.00
Over the Credit Limit Fee	$25.00	$25.00	$25.00
Card Replacement Fee	$10.00	$10.00	$10.00
PIN Replacement Fee	$2.00	$2.00	$2.00

This information is accurate as of 02/23/2010 and is subject to change after that date.

Please contact the credit union at 1-800-526-0579 for any changes to this information.

• Are you a U.S. citizen or permanent resident alien? *
  Yes No
• Do you currently have any outstanding judgements or have you ever filed for bankruptcy, had a debt adjustment plan confirmed under Chapter 13, had property foreclosed upon or repossessed in the last 7 years, or been a party in a lawsuit? *
  Yes No
• Is your income likely to decline in the next two years? *
  Yes No
• Are you a co-maker, co-signer or guarantor on any loan not listed? *
  Yes No
• Name of other obliged to loan
• Name of other loan creditor.

Joint Applicant

Are you a U.S. citizen or permanent resident alien? *

Yes No

Do you currently have any outstanding judgements or have you ever filed for bankruptcy, had a debt adjustment plan confirmed under Chapter 13, had property foreclosed upon or repossessed in the last 7 years, or been a party in a lawsuit? *

Yes No

Is your income likely to decline in the next two years? *

Yes No

Are you a co-maker, co-signer or guarantor on any loan not listed? *

Yes No

Name of other obliged to loan

Name of other loan creditor.

NOTICE TO OHIO RESIDENTS: The Ohio laws against discrimination require all creditors make credit equally available to all credit worthy customers, and that credit reporting agencies maintain separate credit histories on each individual upon request. The Ohio Civil Rights Commission administers compliance with this law.

WISCONSIN RESIDENTS ONLY: (1) No provision of any marital property agreement, unilateral statement under Section 766.59, or court decree under Section 766.70 will adversely affect the rights of the Credit Union unless the Credit Union is furnished a copy of the agreement, statement or decree, or has actual knowledge of its terms, before the credit is granted or the account is opened. (2) Please sign if you are not applying for this account or loan with your spouse. The credit being applied for, If granted, will be incurred in the interest of the marriage or family of the undersigned.

IN SUBMITTING THIS FORM: You promise that everything you have stated in this request is correct to the best of your knowledge. If there are any important changes, you will notify us in writing immediately. You also agree to notify us of any change in your name, address or employment within a reasonable time thereafter. You authorize the credit union to obtain credit reports in connection with this request. If you request, the credit union will tell you the name and address of any credit bureau from which it received a credit report on you. You understand that it is a federal crime to willfully and deliberately provide incomplete or incorrect information on requests made to Federal Credit Unions or State Chartered Credit Unions insured by the NCUA. You understand that the credit union will rely on the information in the request and your credit report to make its decision.

By submitting this loan request, you agree that the information is correct to the best of your knowledge. You also agree to notify us of any changes to your name, address or employment.

By submitting this loan application you authorize the credit union to obtain credit reports in connection with this request.