Phone Number057 86 23336Phone Number057 86 23216
 
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Portarlington Credit Union @fb
Portarlington Credit Union Limited
LOAN APPLICATION FORM
Please complete all your details in the form below, and click submit when you have finished.
Note that elements marked, * are REQUIRED and MUST be completed.
Personal Details
Account Number *
Joint Account Number (if any)
Member Name *
Member Address *
If less than 3 years
Previous Address
Type of Accommodation *
If Other, please specify:
Tel Home *
Tel Work
Mobile Number
e-Mail Address *
Date of Birth (dd/mm/yyyy)
Marital Status *
No. of Dependants
 
Employment Details
Employer *
Work Address *
Occupation *
Length of Service *
Weekly Salary * €
Other Income €
Payroll Number
 
Spouse/Partner’s Details (where relevant)
Spouse/Partner’s Name
Spouse/Partner’s Employer
Employer Address
Spouse/Partner’s Occupation
Spouse/Partner’s Weekly Income €
Any Other Income €
Spouse/Partner’s Date of Birth (dd/mm/yyyy)
 
Current Financial Situation
I declare that I am indebted to the following:
  Original Amount Balance Outstanding Monthly Repayment Amount
Bank  €  €  €
Rent/Mortgage  €  €  €
Credit Cards  €  €  €
Other  €  €  €
Current Share Balance *  €
Mortgage Provider *
Current Deposit Balance  €
Current Loan Balance  €  
Current Arrears  €  
Loan Details
Amount Applied for * €
Purpose Of Loan *
Date Required *
To be repaid every *
Proposed repayment * €
New Loan + Current Loan Balance * €
 
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 knowlewdge and belief.

 *
I declare that to the best of my knowledge  *
I am in good health.
I am NOT in good health.
And that  *
I am fit to follow my normal occupation.
I am NOT fit to follow my normal occupation.
Signature of Applicant
Date Signed
(dd/mm/yyyy)
Name of Guarantor (if required)
Guarantor’s relationship to Applicant
 

Declaration — Data Protection

Data Protection Act 1988 - I consent to the information contained in this application form being used by the Credit Union for the purposes of processing my application.

 *
 
      

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Portarlington Credit Union Limited, is regulated by the Central Bank of Ireland
.
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