NorState FCU-Maine, USA




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Federally Insured by NCUA

Personal Details
E-Mail:
First Name:
Middle Initial:
Last Name:
Address:
Monthly Rent: (if applicable)
City, State, Zip:
Home Phone:
Work Phone:
Employer Name:
Employer Address:
Position:
Date of Employment:
Hours Weekly:
Income:	Gross Monthly
Loan Details
Loan Amount
Loan Type	Vehicle Signature Real Estate Home Equity Other
Term	Months
Purpose

If you are purchasing or refinancing the purchase of a primary residence, please answer the following OPTIONAL fields:

Personal Details
Race/National Origin:	American Indian/Alaskan Native Black Asian or Pacific Islander White Hispanic Other (Specify)
Sex:	Male Female
Marital Status :	Married Unmarried Seperated
Date of Birth:

NOTICE: This information is being requested by the Federal Government to monitor compliance with federal statutes which prohibit credit unions from discriminating on those bases against applicants for a loan or other service, and that the credit union is required to note the race and sex on the basis of sight/surname if the applicant refuses to provide the information.

* By submitting this application, you are authorizing NorState Federal Credit Union to pull a Credit Bureau Report.

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