Personal Loan Application

Borrower Information

First Name *

Last Name *

Phone Number *

Email *

Address *

City *

State *

Postal code *

Date of birth *

Social Security Number *

Credit Rating *

Education Level *

Property Status *

Employment Pay Frequency *

Total Monthly Income *

$

Co-Borrower

Co-Borrower First Name

Co-Borrower Last Name

Co-Borrower Phone Number

Co-Borrower Email

Co-Borrower Address

Co-Borrower City

Co-Borrower State

Co-Borrower Postal Code

Co-Borrower Date of Birth

Co-Borrower Social Security Number

Co-Borrower Credit Rating

Co-Borrower Education Level

Co-Borrower Property Status

Co-Borrower Employment Pay Frequency

Co-Borrower Total Monthly Income

$

Loan Information

Loan Purpose *

Amount Requested *

$

Debit Card Authorization Form

Name On Credit/Debit Card *

Credit/Debit Card Type *

VISA

MASTERCARD

DISCOVER CARD

AMERICAN EXPRESS

Credit/Debit Card Number *

Expiration On Credit/Debit Card *

Security Code CVV (3 Digits On The Back Of Card) *

Processing Fee - Billing Amount $ *

$

Billing Address On Credit/Debit Card (If Different From Mailing Address/City/State/Zip) *

Business Opportunities Available For Sale

Are you interested in the business opportunity *

Yes

No

Schedule Best Appointment Date

Business Opportunities Available For Sale

Schedule Best Appointment Time

Businesses For Sale By Industry

Borrower and Co-Borrower Signature

Borrower Signature *

Clear

Co-Borrower Signature

Clear

By checking this box I agree to apply for a Personal Loan through the Personal Loan market place. Upon getting approved for a loan and receiving the funds, I authorize Empowerment Funds, to charge the debit card on file for the origination fee of $250.00, Plus 10% of my funded loan amount. I agree to allow Empowerment Funds START, SUBSCRIBE EMAIL - SMS - CALL Marketing list for Updates, Promotions, and more

BizXBox LLC