Loan Application Form

All boxes must be filled out, if it does not apply to you, enter N/A

Tell Us About Yourself

Name *

First

Middle

Last

SSN *

Street Address *

Apt. #

City *

State *

Zip Code *

Cell Phone # *

Additional Phone #

Email Address *

Date of Birth *

Time at Address? *

Rent or Own? *

Rent
Live w/Parents
Own
Other

If Other, please specify:

Income

Employer/Source of Income *

Employer Telephone # *

Date of Hire *

Monthly Income *

Additional Income $

Expenses

Rent/Mortgage *

How much do you pay per month?

Cable/Internet *

How much do you pay per month?

Car Payment *

How much do you pay per month?

Cell Phone *

How much do you pay per month?

Car Insurance *

How much do you pay per month?

Credit Cards/Loans *

How much do you pay per month?

Utilities *

How much do you pay per month?

Food *

How much do you pay per month?

References Please List 4 (Parents, Relatives, Friends not living with you)

Name *

Relationship *

Cell Phone *

Name *

Relationship *

Cell Phone *

Name *

Relationship *

Cell Phone *

Name *

Relationship *

Cell Phone *

Collateral/Security - Item #1 (All loans will be Secured = Must have Collateral) *

Example: Car Title, TV, DVD Player, Stereo, Jewelry, Computer, Tools, Equipments, Firearms etc.

Collateral/Security Item #2 (All loans will be Secured = Must have Collateral) *

Example: Car Title, TV, DVD Player, Stereo, Jewelry, Computer, Tools, Equipments, Firearms etc.

Amount Financing

I would like to apply for the following amount ($50.00 - $1,600.00) *

Reason for Loan Application: *

If an employee of Cliff's referred you, who was the employee?

Release of Information

Supporting Documents: Proof of Income, Proof of Residence, Identification

Click or drag files to this area to upload. You can upload up to 3 files.

Digital Signature: (Please read before signing) *

Release of Information: I promise that the information I have provided on this form is correct. I authorize verification of all information on this application for the purpose of obtaining this cash advance and all renewals or extensions thereof. Everything I have stated in this application is correct to the best of my knowledge. Cliff's Finance Co. is authorized to check my credit and employment history and provide credit reference to any company I authorize.

Date: *

Email *