Personal Information
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Driver License #
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Employment Information
Are you currently employed, and have been for three months?
How many hours do you work per shift? (per day)
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day
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swing
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Supervisor's Name
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Are you, your spouse or someone who claims you as a dependent currently in the Military?
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Bank Information
Do you have an active checking account?
Bank name
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Bank routing number
Bank account number
How long have you had your account at this bank?
How many outstanding loans do you have?
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Months
Requested loan amount
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$100
$200
$300
$400
$500
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References
First reference's full name
Second reference's full name
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First reference's relationship
Second reference's relationship
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other
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other
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