Credit Union of The Berkshires

Amount Requested:
Loan Purpose:
Term:

APPLICANT
Name:
Social Security#:
Date of Birth:
Phone:
Address:
City, State, Zip:

Current Employer:
Name:
Address:
City, State, Zip:
Employer ID#:
Self Employed:	Yes No
Supervisor:
Your Title:
Start Date (mm/dd/yyyy):

I hereby certify that all information contained in this application is furnished for the purpose of obtaining the loan requested herein and is true to the best of my knowledge and belief. I further certify that no consideration has passed of will pass from me, as borrower, to an endorser for his endorsement or to co-maker for his signature. You are authorized to check my credit and employment history and to answer questions about your credit experience with me.

I have assisted the Credit Union in the perparation of this application; I have provided the Credit Union with all of the information contained therein; I hereby certify that this loan application is truthful and complete to the best of my knowledge and that I have read the entire completed application before signing same.