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Member Details

Account Number *

Member Name *

Member Address *

Postcode

Previous Address (If less than 3 years)

Type of Accommodation *

If Other, please specify

Mobile Phone *

Day Time Telephone Number

E-mail Address *

Date of Birth *

Marital Status *

Number of Dependants

Employment Details

Employer *

Work Address *

Occupation *

Length of Service *

Weekly Salary *

Other Income

Payroll Number

Employers Email

Spouse/Partners Details (where relevant)

Spouse/Partners Name

Spouse/Partners Employer

Employers Address

Spouse/Partners Occupation

Spouse/Partners Weekly Income

Any Other Income

Spouse/Partners Date of Birth

Current Financial Situation

I declare that I am indebted to the following:

Original Amount

Balance Outstanding

Monthly Repayment Amount

Bank/Building Society

Bank/Building Society-OA

Bank/Building Society-BO

Bank/Building Society-MRA

Rent/Mortgage

Rent/Mortgage-OA

Rent/Mortgage-BO

Rent/Mortgage-MRA

Credit Card

Credit Card-OA

Credit Card-BO

Credit Card-MRA

Other

Other-OA

Other-BO

Other-MRA

Previous Credit Union Loans

Amount

Date

Repayment Amounts

Repayment Frequency

Amount1

Date1

Repayment Amounts1

Repayment Frequency1

Amount2

Date2

Repayment Amounts2

Repayment Frequency2

Amount3

Date3

Repayment Amounts3

Repayment Frequency3

Current Savings Balance(s) *

Current Loan Balance(s)

Current Arrears

Loan Details

I wish to apply for a loan of *

Purpose of Loan *

Date Required *

To be repaid every *

In installments of *

Declaration

I declare that I am not indebted to any other Credit Union, Bank or Loan Agency either as a borrower or Guarantor, except as stated on this application. The statements herein are made for the purposes of obtaining the loan and are true to the best of my knowledge and belief.

I declare that to the best of my knowledge *

I am in good health

I am NOT in good health

Consent for storing submitted data *

Yes, I give permission to store and process my data

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Ballinderry Bridge Credit Union