SmartCare Loan Application

You must be a Campus Federal Credit Union member of borrowing age prior to receiving funds from this loan.

Please Review Carefully Prior to Submitting Your Loan Application:

* = Required

Loan Information

Clinic

Amount Requested* (No dollar signs, commas.)

Loan Term* (Months)

Loan Purpose

Loan Description*

Applicant Information

First* Middle Last* Suffix

Date of Birth* Must be in mm/dd/yyyy format (Must be at least 18 years of age)

Social Security Number* Must be in xxx-xx-xxxx format

Number of Dependents

Street Address*

City* State* Zip*

Housing Status* Occupancy Duration*: Year(s) Month(s)

Housing Payment($)* (No dollar signs, commas.)

Home Phone* Must be in xxx-xxx-xxxx format

Cell Phone Must be in xxx-xxx-xxxx format

Drivers License* State* Expiration Date* Must be in mm/dd/yyyy format

Email Address

Employment Information

Employment Status*

Occupation* Employment Duration* Year(s) Month(s)

Employer*

Employer Address

City State Zip

Work Phone* Must be in xxx-xxx-xxxx format

Monthly Income Information

Gross Monthly Income (Included Spousal income if applicable)

Other Income 1($) (No dollar signs,commas)

Other Income 1 Description

Other Income 2($) (No dollar signs,commas)

Other Income 2 Description

†Alimony, child support and separate maintenance income do not need to be revealed if you do not wish to have them considered as a basis for repaying this obligation.

Applicant Acknowledgement:

Smart Care Account. I agree that, if my application for an Account is granted on the credit terms I have requested, I will be bound by the terms of the Smart Care Account Agreement (“the Agreement”), which will govern my Account. If this Application is approved, the Smart Care Account Agreement will be delivered to me before my first use of the Account, and my Smart Care Card will be delivered to me separately by mail.
Joint and Several Liability. I understand that, among other things, the Agreement makes each Borrower responsible for paying the entire amount of credit extended under my Account.
Contacting Me. I consent to you and any other owner or servicer of my Account contacting me about my Account, including using any contact information or cell phone numbers I provided (whether now or in the future), and I consent to your use of any automatic telephone dialing system and/or artificial or prerecorded voice when contacting me, even if I am charged for the call under my phone plan.
Governing Law. This Application and the Agreement are governed by Federal law and Louisiana law (to extent that state law applies).
Smart Care plans / terms are subject to availability by your Clinic.

Consent and Authorization

I certify that the information on this Application is complete, true, and submitted for the purpose of obtaining a Smart Care Account (“Account”) from Campus Federal Credit Union. I agree: (a) that you can use credit reporting agencies or other sources to verify the information on this Application for the purpose of extending credit to me or reviewing or collecting a credit account of mine; and (b) that you can tell others about your credit experience with me and obtain information from others about my credit history and performance. At my request, you will tell me the name and address of any credit reporting agency from which you received my credit report.

I/we have read and agree to the above Authorization.