SDL APPLICATION FORM

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Small Dollar Loan Application Form

Personal Information

First Name

Last Name

Resident Status:

U.S Citizen

Permanent Resident

If Non-Permanent Resident

Indicate Country of Citizenship:

Date of Birth:

SSN:

Loan Information

Loan Purpose:

Payment of medical bills

Payment of rent and utilities

Payment of loans to banks/ other lending institutions

Children's school fees

Purchase of personal vehicles

Other emergency purposes

(e.g., due to illness of family members),

please specify:

Request Loan Amount:

(Note: $2,500 maximum)

Term (in months):

(Minimum: 3 months, Maximum: 12 months, Interest rate ranges from 7.5% - 12%)

Contact Information

Primary Phone Number

(mobile preferred):

(Please provide a U.S. Phone Number

* If you wish to have an alternative phone number, kindly fill out below details.

Alternate Phone Number

(mobile preferred):

(Please provide a U.S. Phone Number

Email

Current Address:

City:

Country:

Zip Code:

* If you have a different mailing address, kindly fill out below details,

Mailing Address:

City:

Country:

Zip Code:

Occupancy Status:

Rent

Own

Other

How long have you lived at your current address?

(input 0, if less than 1 year)

Thank you for sending your application!

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