Thriven Functional Medicine – Russell Country Federal Credit Union

Application Type *

Amount Requested *

Purpose *

Applicant First Name *

Applicant Last Name *

Applicant Address *

SSN or TIN *

Birthdate *

Phone Type *

Phone Number *

Email Address *

Residential Status *

Years at Address *

If Other, please describe *

If you selected Other for Residential Status, please describe.

Mortgage/Rent Owed To *

Name/Address of Employer *

Employment Income Type *

Employment Income *

Other Income

(Alimony, child support, or separate maintenance income need not be revealed if you do not choose to have it considered as a basis for repaying this obligation.)

Source of Other Income

Clinic Contact *

Comments

Joint Applicant

Joint Applicant First Name *

Joint Applicant Last Name *

Joint Applicant Address *

Joint Applicant SSN or TIN *

Joint Applicant Birthdate *

Joint Applicant Phone Type *

Joint Applicant Phone Number *

Joint Applicant Email Address *

Joint Applicant Residential Status *

Joint Applicant Years at Address *

If Other, please describe *

If you selected Other for Residential Status, please describe.

Joint Applicant Mortgage/Rent Owed To *

Joint Applicant Name/Address of Employer *

Joint Applicant Employment Income Type *

Joint Applicant Employment Income *

Joint Applicant Other Income

(Alimony, child support, or separate maintenance income need not be revealed if you do not choose to have it considered as a basis for repaying this obligation.)

Joint Applicant Source of Other Income

By clicking the "Submit" button below, you promise that everything you have stated in this application is correct to the best of your knowledge. If there are any important changes, you will notify us in writing immediately. You authorize the Credit Union to obtain credit reports in connection with this application for credit and for any update, increase, renewal, extension, or collection of the credit received. Additionally, you authorize a representative of the Credit Union to disclose and discuss your loan application information and loan decision with a representative of the referring business.