Short Term Loan * Required Fields To qualify the following criteria must be met: Monthly Direct Deposit: Yes No Gross income of at least $1,000/month: Yes No Active checking account for at least 90 days: Yes No Continuous employment for the last six months: Yes No I'm 18 years or older: Yes No All accounts are currently in good standing (Including Loans and Credit Cards): Yes No Don't currently have a Short Term Loan with Pinal County FCU at this time: Yes No Not looking to pay off one Short Term loan with another: Yes No Business Accounts are not eligible: Yes No If you answered NO to any of the above questions you are not eligible for a Short Term Loan at this time. Please come back again when you meet the eligibility criteria. Thank you! Are you currently involved in any bankruptcy proceedings? Yes No If you answered YES, you are not eligible for a Short Term Loan at this time. Please come back again when you meet the eligibility criteria. Thank you! Amount Requested: (BETWEEN $500.00 AND $1000.00) 1. Applicant Information Name (Last/First/Initial): Account Number: Social Security Number: Birth Date: Home Phone: Business Phone/Extension: Email Address: Married Separated Unmarried (single-divorced-widowed) Present Address: Present Address 2: City: State: Select... AL AK AZ AR CA CO CT DE DC FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY ZIP: 2. Employment Information Name and Address of Employer: Number of hours worked per week? Your Title: Start Date: Supervisor's Name: If Self Employed: Type of Business: Name and Address of Employer: Hours: Your Title: Start Date: Supervisor's Name: If Self Employed: Type of Business: 3. Income Information NOTICE: Alimony, child support, or separate maintenance income do not need to be revealed if you choose not to have it considered. Employment Income Amount: Per: Gross: Select... Yes No Other Income Amount: Per: Gross: Select... Yes No Attach Pay Stubs: 4. References Nearest Relative Not Living with You Name and Address: Home #: Work #: Name and Address: Home #: Work #: Cell #: If there are any important changes, you will notify us in writing immediately. You also agree to notify us of any change in your name, address or employment within a reasonable time hereafter. You also promise that everything you have stated in this application is correct to the best of your knowledge and that the above information is complete. You understand that it is a federal crime to willfully and deliberately provide incomplete or false and misleading information. I accept the terms of the disclaimer above and submit my application. Date: Security Code: Security Code Go to main navigation