| Section
A: Borrower Section-------------------------------------------------------------------------- |
| *Requested
Total Loan Amount $ |
|
| *Repayment
Terms (years) |
|
| *Deferred
Payments : |
|
| * |
|
| *First
Name, Middle Init, Last Name |
|
| *Street
Address / Apt# Rural Route |
|
| *City,
State, Zip |
|
| *How
Long at Current Address (yrs/mos) |
|
| (Prior
Address if less than 1 year) Street Address |
|
| City,
State, Zip |
|
| *Social
Security # |
|
| *Driver's
License # |
|
| *Date
of Birth (mm/dd/yyyy) |
|
| *Email
Address |
|
| *U.S.
Citizen |
|
| * |
|
| * |
|
| *Do
you Rent / Own or Live w/Parents |
|
| * |
|
| * |
|
| Monthly
Mortgage / Rent $ |
|
| *Home
Phone # (area code/prefix/numbers) |
-
-
|
Mailing
Address
(if different) Address, City, State, Zip) |
|
| *Work
Phone # (area code/prefix/numbers) |
-
-
|
| *Employer
Name |
|
| *Employer's
Street Address |
|
| *Employer's
City, State & Zip |
|
| *Position
/ Title |
|
| *Length
at Current Employer (yrs/mos) |
|
| *Gross
Monthly Salary $ |
|
| Previous
Employer Name |
|
| Length
at Previous Employer(yrs/mos) |
|
| Other
Income |
|
| Source
of Other Income |
|
|
Please
Provide Two References-------------------------------------------------------------------------- |
| *Reference
Name (do not use co-borrower) |
|
| *Reference's
Address, City, State and Zip |
|
| *Reference's
Home Phone |
|
| *Relationship |
|
| *Reference
Name (do not use co-borrower) |
|
| *Reference's
Address, City, State and Zip |
|
| *Reference's
Home Phone |
|
| *Relationship |
|
|
Section
B: Co-Borrower Section-------------------------------------------------------------------------- |
| Co-Borrower
Relationship to Borrower |
|
| First
Name, Middle Init, Last Name |
|
| Street
Address / Apt# Rural Route |
|
| City,
State, Zip |
|
| How
Long at Current Address (yrs/mos) |
|
| (Prior
Address if less than 1 year) Street Address |
|
| City,
State, Zip |
|
| Social
Security # |
|
| Driver's
License # |
|
| Date
of Birth (mm/dd/yyyy) |
|
| Email
Address |
|
| U.S.
Citizen |
|
|
|
|
|
| Do
you Rent / Own or Live w/Parents |
|
|
|
|
|
| Home
Phone # (area code/prefix/numbers) |
-
-
|
Mailing
Address
(if different) Address, City, State, Zip) |
|
| Monthly
Mortgage / Rent $ |
|
| Work
Phone # (area code/prefix/numbers) |
-
-
|
| Employer
Name |
|
| Employer's
Street Address |
|
| Employer's
City, State, Zip |
|
| Position
/ Title |
|
| Length
at Current Employer (yrs/mos) |
|
| Gross
Monthly Salary $ |
|
| Previous
Employer |
|
| Length
at Previous Employer (yrs/mos) |
|
| Other
Income |
|
| Source
of Other Income |
|
|
|
|
*
denotes required field |
