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					Rugby Credit Union Limited
                                                                                                                       Loan No
Loan Application Form


Please complete all sections of the form in BLOCK CAPITALS. If you need help in completing
the form, staff or volunteers in the Credit Union will be pleased to assist.
Please note that if you wish us to consider a guarantor on the loan he/she should also complete an application
form, clearly marked “Guarantor details”.

*Please delete as applicable.

Member Details:

Name……………………………………..……………….……….. Membership number……………

Address ……………………………………………………………………………………………….….

……………………………………………………………………..……..Postcode…………………….

Time at current address……………………………. (If less than 3 years, please provide details of other
addresses in the past 3 years on a separate sheet).

Date of birth………………………..National Insurance number…………………………………..…

Home telephone number ……………………………………

Employment/Benefit Details
Employment status *employed/self-employed/retired/unemployed
Benefits: Please enter on reverse of this form

Occupation ………………………………………………………………………………..…..

Name of Employer …………………………………………………………………………………….

Work Telephone number …………………………….Can you be contacted here * Yes/No

Time with current employer ……………………. (if less than one year, please provide details of previous
employment on a separate sheet)


Please note:
If you are employed you will be asked to provide 2 months payslips and bank statements for 3 months.
If you are on benefits proof of the benefits you are receiving plus bank statements for 3 months.

Loan Details

Purpose of loan ……………………………………………………………………………………….

Amount requested £…………………… Suggested repayment period ……………months/weeks

Data Protection Statement: In accordance with the principles of the Data Protection Act 1998, we will use your personal details for the
purposes of managing your accounts with the Credit Union. Your personal details will be treated confidentially and will only be shared with other
agencies for the purposes of credit referencing and debt recovery, for which purpose we hold a Category F consumer credit licence.
We may at time use your details to keep you informed of services available from the Credit Union.
If you wish your details to be used for these marketing purposes, please tick this box




RBCU LA/3
09/09
Income and Expenditure Details
Income Item                                  £             £             Income Item                                   £             £
                                             Weekly        Monthly                                                     Weekly        Monthly
Salary/wages                                                             Income Support
Partner’s income                                                         Tax Credits
Pension                                                                  Incapacity Benefit
Other Income (please specify)                                            Disability Living Allowance
                                                                         Other Benefits (please specify)

                                                                         Total Income

Expenditure Item                                                         £ Weekly            £ Monthly         £Annual           Outstanding
                                                                                                                                 Balance
Rent/mortgage*
Council tax
Water
Electricity
Gas/oil/coal
Food/shopping
Telephone (incl mobile)
TV Licence
Internet/Sky/Cable
Clothing
Vehicle servicing/repairs/road tax/MOT
Car insurance
Life Insurance
Home insurance
Travel (incl petrol if applicable)
Holidays
Catalogues
Credit cards
Credit Union Loans
Social Fund Loan
Other loans (incl bad debt repayments)
Pension contributions
Savings/investments (incl Credit Union)
Meals out/takeaways/drinks
Christmas/birthdays
Pets
Other (please specify)
Total Expenditure

Partner’s Declaration
If you have declared your partner’s income details as part of your overall income in applying for this loan, your partner will need to sign
below confirming agreement for their information to be used in considering the loan and its repayment.

Partner’s name ……………………………..Partner’s signature ………………………………..

Formal Declaration
I declare that I am/am not* in good health and that I do / don’t* require regular medical treatment. (If you are not in good health, please
complete the credit union medical form for insurance purposes).

I/We authorise Rugby Credit Union to make such enquiries as it considers necessary in relation to my/our loan application and to search my
details with a credit reference/fraud prevention agency/agencies. Any search will be recorded and stored by the agency and may
influence the lending or fraud prevention decisions of other organisations

I declare that the information I have given on this form is, to the best of my knowledge and belief, accurate and full information. I
understand that the provision of false information is fraud and that the Credit Union may take appropriate action if I am found to have
deliberately provided false or misleading information.

Applicant’s signature ………………………………….. Date ……………………………….
Official Use Only:

Date received ……………………………..……… Decision * approved/refused/referred Interviewer………………………………..

Comments and reasons………..…………………………………………………………………………………………….…

Date member informed ………………………… Authorised signatory ………….……………/…………….………….
RBCU LA/3
09/09

				
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