Private Loan Application ≡ Fill Out Printable PDF Forms Online

Question	Answer
Form Name	Private Loan Application
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	Suffix, BORROWER, GPA, Signatories

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Delta Financial Solutions, Inc.

Private Loan Application/Promissory Note and Credit Agreement

Page 1 of 2

STUDENT BORROWER INFORMATION

____________________________	__________________________		_____		___________	________________________________
Last Name	First Name		MI		Suffix (Jr, III)	Social Security Number (SSN)
__________________________________________________________			___________________			________________________________
Government Issued Identification and Name of Government Agency			State of U.S.			ID#
______________________________________________		_________		___________________		____________	________________
Permanent Street Address (PO boxes not accepted)		Apt		City		State	Zip
__________________________	___________________	____________________________________________________________________
Permanent Telephone Number	Date of Birth	Email Address

(if less than 5 years at current address please fill out prior mailing address below)


______________________________________________			_________	___________________	____________	____________
Current Street Address (if different from permanent address)			Apt	City	State	Zip
______________________________________________			_________	___________________	____________	____________
Prior Mailing Address (if less than 2 years at current address)			Apt	City	State	Zip
Please check one	_____US Citizen	_____Permanent Resident

School I am or will be attending:

Saint James School of Medicine

Academic period from: ___________________________________________

LOAN REQUEST INFORMATION:

$_________________ (not to exceed $4,500 in any one semester or $___________________ in the aggregate).

Semester Loan is being applied for: ______________, 20_______

(This amount will be automatically reduced to reflect the aggregate education loan limits, aggregate loan program limits or annual borrowing limits associated with the loan program you have selected or to reflect a lesser amount certified by your school)

REPAYMENT TERMS:

Any loan request will be handled and evaluated separately and there shall be no obligation to make any loan. Students must remain enrolled and in good standing with a GPA of at least 3.0 and all fees paid in order to qualify for any loan. Terms and interest rate will be determined according to Delta Financial Solutions, Inc.

EMPLOYMENT INFORMATION
____________________________________	_________________	_____	______	____________________________________
Name of Current Employer	Occupation	Years	Months	Work Telephone Number
		(time at present Employer)
____________________________________	_____________	_________________		_________________	____________
Employer Street Address	Ste.	City		State	Zip

(Alimony, child support or separate maintenance income do not need to be revealed if you do not wish to have it considered as a basis for repaying this loan.)


Household Income:	_________________________________
____________________________________		_________________	_____	______	____________________________________
Name of Previous Employer		Occupation	Years	Months	Work Telephone Number
(if less than 2 years at current position)			(time at previous Employer)

REFERENCE INFORMATION (Reference cannot be the cosigner, the same person as the cosigner’s reference, or live with either you or the cosigner)

____________________________	__________________________		_________________		_____________________________
Last Name	First Name		Telephone Number		Relationship to Student
______________________________________________		_________		___________________		____________	____________
Street Address		Apt		City		State	Zip

								Page 2 of 2
COSIGNER INFORMATION
____________________________	__________________________		_____		___________		________________________________
Last Name	First Name		MI		Suffix (Jr, III)		Social Security Number (SSN)
__________________________________________________________			___________________				________________________________
Government Issued Identification and Name of Government Agency			State of U.S.				ID#
______________________________________________		_________		___________________			____________	________________
Permanent Street Address (PO boxes not accepted)		Apt		City			State	Zip
__________________________	___________________	____________________________________________________________________
Home Telephone Number	Date of Birth	Email Address
I have lived at my permanent address for:		Years ___________				Months ____________

(if less than two years at current address please fill out prior mailing address)

Please check one	_____Rent		_____Own	_____Other		_______________________			____________________________
						Rent or Mortgage Payment			Current Telephone Number
Relationship to Student Borrower		__________________________________________________
______________________________________________				_________		___________________			____________	____________
Prior Mailing Address I have lived at				Apt		City			State	Zip
I lived at this prior address for:	Years ___________			Months	____________
EMPLOYMENT INFORMATION
____________________________________			_________________		_____		______	____________________________________
Name of Current Employer			Occupation		Years		Months	Work Telephone Number
					(time at present Employer)
____________________________________			_____________		_________________			_________________		____________
Employer Street Address			Ste.		City			State		Zip
Annual Income: _________________________________
____________________________________			_________________		_____		______	____________________________________
Name of Previous Employer			Occupation		Years		Months	Work Telephone Number
(if less than 2 years at current Employer)					(time at previous Employer)

REFERENCE INFORMATION (Reference cannot be the borrower, the same person as the borrower’s reference, or live with either you or the borrower)

____________________________	__________________________		_________________		_____________________________
Last Name	First Name		Telephone Number		Relationship to Cosigner
______________________________________________		_________		___________________		____________	____________
Street Address		Apt		City		State	Zip

If the school is considered to be a business subject to the Federal Trade Commission rules, then the following notice applies:

NOTICE: ANY HOLDER OF THIS CREDIT AGREEMENT IS SUBJECT TO ALL CLAIMS AND DEFENSES WHICH I COULD ASSERT AGAINST THE SCHOOL FOR THE SERVICES OBTAINED WITH THE PROCEEDS HEREOF. RECOVERY HEREUNDER BY ME SHALL NOT EXCEED AMOUNT PAID BY ME HEREUNDER.

Official Use Only

Loan Approved: _____ Loan Not Approved: _____

Amount of Loan Approved: $__________

Interest Rate for Loan: __________ Percent (_____%)

Semester for which Loan is being made: ________, 20____

Date of First Enrollment in School: ____________________

Date: ________, 20____

Authorized Signatories:

___________________________ ________________________

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