Notice: Alimony, child support or separate
maintenance income need not be revealed if
you do not choose to have it considered.

*Application Type

*This will be an:

Individual Application

Joint Application

*Loan Type

New/Used Vehicle

Payment Advantage

Signature

Visa Card

Share/CD Secured

Other Loan Type

If other is checked,
indicate type of loan:

*Amount Requested:

*This will be a:

New Account

Loan Increase

Applicant Information

*Name (Last, First, Middle Initial)

*Mazuma Acct. No.

*Social Security No.

*Date of Birth

No. of Dependents

*Street Address

*City, State, Zip Code

*Home Phone No.

E-mail Address

*Years at Address

*Do you
Own or Rent
your home?

*Mortgage or Rent
Payment Amount

*Mortgage Holder

*Present Balance

*Estimated Value

*Former Street Address

*City, State, Zip Code

*Years There

Applicant Employment Information

*Employer

*Work Phone No.

*Employer's Street Address

*City, State Zip Code

*Years There

*Position

*Gross Income

*Per (Month, Year, Hour)

*Former Employer

*Years There

*Former Employer's Street Address

*City, State Zip Code

Personal References

*Full Name (relative)

Street Address

City, State, Zip Code

Phone No.

*Full Name (friend)

Street Address

City, State, Zip Code

Phone No.

Joint Account Applicant Information

Name (Last, First, Middle Initial)

Date of Birth

Social Security No.

Street Address

City, State, Zip Code

Relationship to Applicant (if any)

Phone No.

E-mail Address

Employer

Work Phone No.

Employer's Address

City, State, Zip Code

Years There

Position

Gross Income

Per (Month, Year, Hour)

Additional Services

Would you like to include?

Credit Life

Disability

GAP

Extended Warranty

Additional Comments

Please enter any additional
comments that you would like to
include with this application.