NOTE: If you are a current or former borrower – Please click on LOAN REQUEST APPLICATION link. If you are a new applicant and live within 25 miles of our office location-please complete the following application. Required fields are marked with an * Step 1 of 6 16% Loan Request ApplicationDate* Amount Requested:*Proceeds of Loans to be used for:*How did you learn of us:--Please Select--Previous CustomerInternet SearchFriendOther***IMPORTANT: Please be sure to enter your FULL name (including your MIDDLE or MAIDEN name) as it appears on your NC ID or NC Driver's License***Applicant First Name*Applicant Middle Name****If no middle name enter NMI***Applicant Last Name*Email:* Social Security: (123-45-6789)*US Citizen:*YesNoActive Military:*YesNoIf yes, do not complete the application on line. Please contact our office directly.Dependent of a Military Personnel*YesNoIf yes, do not complete the application on line. Please contact our office directly.Date of Birth:(MM/DD/YYYY)* Physical Residence Address:* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mailing Address (if different): Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone: (555-555-5555)*Cell Phone: (555-555-5555)Date Moved In:* Do you?*--Please Select--OwnBuyRentLive With Whom...Name and #:Enter the name or number of the individual you rent or live with here if it applies. If you designated rent or live with someone a name and phone number of that individual are required.Mortgage/Rent Monthly Payment ($) :*If no payment enter a $0.00Mortgage / Landlord Name: (If Own Home enter OWN)*Landlord Phone # (555-555-5555)*If OWN enter 0'sPrevious Address (If less than 3 years): Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Move In Date of Previous Address: (MM/DD/YYYY) Your Employment InformationYour Employment Information Place Of Employment:*Your Employment Information Place Of EmploymentPosition:*Length Of Employment:*Phone:(555-555-5555)*Net (Take-Home) Pay ($ per month)*Shift:--Please Select--1st2nd3rdPrevious Employment (If less than 3 years)Length Of Previous Employment: Co-Applicant InformationCo-Applicant Info - If Applicable: First Middle Last Cell Phone # (555-555-5555)Social Security: (123-45-6789)Co-applicant Date of Birth: (MM/DD/YYYY) Co-applicant Address: Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code (Not necessary to complete if same address as applicant)Co-Applicant's Employment Info If ApplicablePlace Of Employment:Position:Length Of Employment:Phone: (555-555-5555)Net (Take-Home) Pay ($ per month) Sources of Other IncomeAlimony or child support received under:Court OrderWritten AgreementOral AgreementAlimony or child support income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.Alimony Amount ($)FromAmountFromAmountFromAmount Current Automobile InformationAutomobile #1YearMake (Ford, Chevy, etc.)Model (Mustang, Corvette, etc.)Do you:--Please Select--BuyLeaseOwnIf Financed Creditor:Monthly Payment ($)Balance if Known ($)Automobile #2YearMake (Ford, Chevy, etc.)Model (Mustang, Corvette, etc.)Do you:--Please Select--BuyLeaseOwnIf Financed Creditor:Monthly Payment ($)Balance if Known ($)Have you ever had a repossession?*YesNo Credit InformationBank References CheckingBank Name for CheckingBank References SavingsBank Name for SavingsOpen Accounts: (Credit Cards, Furniture, Loans, Jewelry, Tire Stores, Rentals, Etc)1st Creditor:Monthly Payment ($)2nd Creditor:Monthly Payment ($)3rd Creditor:Monthly Payment ($)4th Creditor:Monthly Payment ($)5th Creditor:Monthly Payment ($)Have you ever filed bankruptcy?YesNoChapter 13Chapter 7Date Filed: (MM/DD/YYYY) Comments:All loan approvals are based on our liberal loan policy and applicants should live within 25 miles of our office location. Some exceptions are made on Auto Loans. After your application is submitted, we will contact you by the next business day. Please provide a phone number and/or your email address in the comments / clarifications section above where you can be reached during the day if we need additional information. Important Read Before Sending Application I (We) represent, warrant, and affirm that I am at least 18 yrs old and all of the above statements in this application are true and correct and have been made in order to induce you to grant credit with knowledge that you will rely thereon. You are authorized to verify the correctness of these statements and to procure any other information which you may require to appraise this application. If credit is not approved, I authorize you to retain the application and credit agreement as your property. I have reviewed your Privacy Policy and Security Statement, in full, and by submitting the above information I (we) hereby authorize(s) you to obtain a consumer credit report from a consumer reporting agency.Credit Application Approval* Approved Please check above to approve your application to be processed.
