L O AN A PPLI C AT ION WO RK S HEET
APPLICANT IN FO RMATION
Name: DL #/State:
Date o f bir th: SSN:
Current Street Address:
City : State: ZIP C ode:
Phone: E-mail : Fax:
Own Re nt O the r (circl e o ne) Monthly payment or r ent: How long?
Pre vious a ddress if a bove is less tha n 2 years:
City: State: ZIP Code :
Owne d Rente d Other (circle one ) Monthly pa yme nt or re nt: How long?
EMPLOYMEN T IN FOR MATI ON
Curre nt e mployer:
Employer address: How long?
Phone: E-ma il: Fax:
City: State: ZIP Code :
Pay rate: $____________ per
Position: Hourly Sal ary (Circl e one)
hr mo yr (cir cle o ne)
Pre vious e mploye r (if less tha n one ye ar):
Address: How long?
Phone: E-ma il: Fax:
City: State: ZIP Code :
Pay ra te: $____________ per
Position: Hourly Sala ry (Circle one )
hr mo yr (circle one )
Name of a rela tive not re siding with you: re lationship:
Address: Phone:
City: State: ZIP Code :
CO-BORROWER I NFORM ATION, I F APPLI CABLE
Name: DL #/State:
Date o f bir th: SSN: Phone:
Current addr ess:
City : State: ZIP C ode:
Phone: E-mail : Fax:
Own Re nt O the r (circl e o ne) Monthly payment or r ent: How long?
Pre vious a ddress if a bove is less tha n 2 years:
City: State: ZIP Code :
Own Re nt O the r (circl e o ne) Monthly payment or r ent: How long?
EMPLOYMEN T IN FOR MATI ON
Curre nt e mployer:
Employer address: How long?
Phone: E-ma il: Fax:
City: State: ZIP Code :
Pay rate: $____________ per
Position: Hourly Sal ary (Circl e one)
hr mo yr (cir cle o ne)
Pre vious e mploye r (if less tha n one ye ar):
Address:
Phone: E-ma il: Fax:
City: State: ZIP Code :
Pay ra te: $____________ per
Position: Hourly Sala ry (Circle one )
hr mo yr (circle one )
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L O AN A PPLI C AT ION WO RK S HEET
REFER EN CE # 1
Name :
Curre nt a ddress:
City: State: ZIP Code :
Phone # Rela tion to you:
REFER EN CE # 2
Name :
Curre nt a ddress:
City: State: ZIP Code :
Phone # Rela tion to you:
LOAN IN FORMATIO N
Hav e yo u ev er defaul ted on a student lo an? Yes No
How long would yo u li ke the pay ments to run? 2yrs 3yrs 5yrs 10 yrs 15yrs
Would y ou li ke to defer the pay ments? 3 months 6 months 12 months
OTHER ASSE TS OR SOUR CES OF INCOME (ALIMONY/ CHILD SUPPO RT E TC.)
Description: Amount per month or va lue
Description: Amount per month or va lue
Comme nts:
SI GNATURE
Signatur e: Date:
**ALL I TEM S IN BOL D ARE RE QUIRED FIELDS **
IF L OAN I S DENIE D SEC TI ON
If my loan i s deni ed I (pri nt name)_________________________________________ her eby giv e
the UTA Admissio ns D epartment approv al to submi t my same lo an i nfor matio n to the followi ng
mar ked fundi ng so urc es.
□ Salli e M ae L oans □ Well s F ar go □ C hase Bank □ C ollegiate Funding
Servi ces
□ Key Educatio n Resour ces □ TE RI Loans □ Other Lo an So urces
Signatur e: Date:
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