Amount Applying For:
Reason for the Loan:
Last name:
First name:
Middle name:
S.I.N.
Date of Birth: (yyyy-mm-dd)
Number & Street:
Apt #:
City:
Province: Ontario Alberta British Columbia Manitoba New Brunswick Newfoundland & Labourador Northwest Territories Nova Scotia Nunavut Prince Edward Island Quebec Saskatchewan Yukon
Postal Code:
Length (years):
Length (months):
Home Phone #:
Cell Phone #:
Email Address:
If At Current Address For Less Than Three (3) Years
Name & Address of Mortgage Holder or Landlord:
Rent/Mortgage Monthly Payment:
Property Taxes:
Mortgage Balance:
Value of Home:
Current Employer Name & Address:
Employer Phone #:
Occupation:
If At Current Employer For Less Than Three (3) Years
Previous Employer Name & Address:
Number of Years:
Gross Monthly Income:
Other Income:
Other Income Source:
Total Income:
Date of Birth:
Province:
Employment length (years):
Employment length (months):
Co gross monthly:
Co other monthly:
Co total income:
By submitting this form you consent to the obtaining of such personal or credit information as Southwest Regional Credit Union may require at any time in connection with the credit hereby applied for, or any renewal or extension thereof: and further consents to the disclosure of any information concerning the undersigned to any credit reporting agency, or any person with whom the undersigned, has or proposes to have financial dealings.
I am not indepted to any other Credit Union, bank, loan agency or individual either as maker or endorser except as stated above. The statements herein are made for the purpose of obtaining this loan and are true to the best of my knowledge and belief.
I/we understand additional information may be required from me/us to complete the credit request such as confirmation of income and I/we will be required to open a membership with Southwest Regional Credit Union that will require supporting documentation such as photo identification.
**Have you ever declared Bankruptcy or part of a Consumer Proposal? Yes
If Yes, date of Discharge:
**Have you ever applied for credit at Southwest Regional Credit Union Ltd. Yes
**I/we agree to allow Southwest Regional Credit Union Ltd. to run a credit check. Yes