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Primary Borrower Information

Name (First M. Last)
Date of Birth (mm/dd/yyyy)
Social Security No.	Do not use hyphens (-).
Member Number
Number of Dependents
E-mail
Send me email updates about Premier’s latest offers	Yes No
Preferred Contact Branch	Ames Branch – 520 Grand Avenue Main Branch – 800 9th Street Skywalk – 700 Locust
Current Address
City, State, ZIP Code	, AKALARAZCACOCTDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNENHNJNMNVNCNDNYOHOKORPARISCSDTNTXUTVTVAWAWIWVWY
Current Home Phone Number
Current Employer
Current Work Phone
Current Job Title
Start Date
Gross Annual Income
Additional Income
Source
Nearest Relative not living with you.
Name
Address
City
State	AKALARAZCACOCTDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNENHNJNMNVNCNDNYOHOKORPARISCSDTNTXUTVTVAWAWIWVWY
ZIP Code
Home Phone

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indicates a required field based upon a previous selection

Co-Borrower Information

The Co-Borrower listed below acknowledges his or her intent to apply for joint credit.
Name (First M. Last)
Date of Birth (mm/DD/yyyy)
Social Security No.	Do not use hyphens (-).
Number of Dependents
E-mail
Current Address
City, State ZIP Code	, AKALARAZCACOCTDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNENHNJNMNVNCNDNYOHOKORPARISCSDTNTXUTVTVAWAWIWVWY
Current Home Phone Number
Current Employer
Current Work Phone
Current Job Title
Start Date
Gross Annual Income
Additional Income
Source
Current Work Address
City, State Zip	, AKALARAZCACOCTDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNENHNJNMNVNCNDNYOHOKORPARISCSDTNTXUTVTVAWAWIWVWY
Current Work Phone Number
Former Address
City, State Zip	, AKALARAZCACOCTDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNENHNJNMNVNCNDNYOHOKORPARISCSDTNTXUTVTVAWAWIWVWY
Former Home Phone Number
Former Employer
Former Job Title
Former Work Address
City, State Zip	, AKALARAZCACOCTDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNENHNJNMNVNCNDNYOHOKORPARISCSDTNTXUTVTVAWAWIWVWY
Former Work Phone Number

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Debts	Monthly Payment

In addition to Rent/Mortgage, list all other debts (for example auto loans, credit cards, second mortgage, alimony, child support, child care, medical, utilities, auto insurance, IRS liabilities, etc.). Please use a separate line for each credit card and auto loan.

Income verification is required; therefore, other information may be necessary.

** Alimony or child support maintenance payments are optional information and need not be revealed if the applicant does not choose to rely on such income in applying for credit.

I certify that statements on this application are true and complete. I authorize any person, association, firm or corporation to furnish, on request of Premier Credit Union, any information concerning my affairs or me. Sec. 1014, Title 13, U.S. Code, makes it a Federal Crime to knowingly make a false statement on this application.

The above information is accurate and posted on this site on 09/15/04. Please call the credit union at (515) 282-1611/toll-free (866) 273-9938 for any changes.