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Long-Term Loan Application

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					                                               Long-Term Educational Loan Application
                                                  (to be completed by student - please Type or Print)

Student Name .................. :
                                        (Formal/Legal Name)
Date of Birth ..................... :
                                        (mm/dd/yyyy)
Social Security Number .... :
                                        (xxx-xx-xxxx)

Local Address ................... :
                                        (Street & Apt #)

                                        (City, State and Zip Code)

                                        (Telephone Number: (xxx) xxx-xxxx)

Permanent Address.......... :
                                        (Street & Apt #)

                                        (City, State and Zip Code)

                                        (Telephone Number: (xxx) xxx-xxxx)

Nearest Relative ............... :
Not Living with You                ( Name)                                                                 (Relationship)

                                        (Street & Apt #)

                                        (City, State and Zip Code)

                                        (Telephone Number: (xxx) xxx-xxxx)

Have you ever filed for bankruptcy or had any judgments filed against you?                 No      Yes – explain below:




Class:        Freshman                    Sophomore                  Junior     Senior          Graduate
           Law (JD):                      1st Year                   2nd Year   3rd Year
           Medicine (MD):                 1st Year                   2nd Year   3rd Year        4th Year

I certify that the statements contained herein are true and that the University of Cincinnati is authorized to obtain any
information, including a credit report, necessary to determine loan eligibility and approval. Furthermore I acknowledge
receipt of the Institutional Long-term Loan Application Disclosure.

Applicant Signature & Date:
                                             (Signature)                                                       (Date)
Revised 02/08/2010

				
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