Simple Loan Application Form

Personal Information

1. Full Name: ___________________________

2. Address: ___________________________

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3. Phone Number: ___________________________

4. Email Address: ___________________________

5. Date of Birth: ___________________________

6. Social Security Number: ___________________________

Employment Information

1. Current Employer: ___________________________

2. Job Title: ___________________________

3. Employment Start Date: ___________________________

4. Monthly Income: ___________________________

5. Other Sources of Income: ___________________________

Loan Details

1. Loan Amount Requested: ___________________________

2. Purpose of Loan: ___________________________

3. Repayment Term: ___________________________

4. Preferred Repayment Schedule: ___________________________

Bank Details

1. Bank Name: ___________________________

2. Account Number: ___________________________

3. Account Type: ___________________________

References

1. Reference Name 1: ___________________________

   Phone Number: ___________________________

2. Reference Name 2: ___________________________

   Phone Number: ___________________________

Declarations

1. I hereby declare that the information provided is accurate and complete.

   Signature: ___________________________

   Date: ___________________________

2. For Official Use Only

   Application Received By: ___________________________

   Date: ___________________________

   Approved/Rejected: ___________________________

   Amount Approved: ___________________________

   Repayment Term: ___________________________

   Notes: ___________________________

Contact Information

1. Loan Officer: ___________________________

2. Phone Number: ___________________________

3. Email Address: ___________________________

Instructions:

• Fill out all fields accurately.
• Attach required documents.
• Submit the form to the designated loan officer.