Instant Loan Request Form

Complete this Instant Loan Request Form online and press submit
OR print it, fill it out and fax it to 651-464-4711
For questions on this application call 651-982-2688
or contact us via email

**All fields are REQUIRED unless otherwise noted**

Amount of Requested :
Description of Purchase:
Choose One: 90 Days Free 12 mo. 24 mo. 36 mo. 48 mo. 60 mo.   or circle choice if faxing:  90 days free   12mo.  24 mo.  36 mo.  48 mo.  60 mo.
Name:
Marital Status:
Social Security #:
Driver's License #:
Birth Date:
Address:
City:
State:                   Zip:
Length of Residence:
Home Phone:
E-mail:
Work Phone:
Employer:
Length of Employment:
Position:
Monthly Net Income:
Previous Employer (type none if this does not apply):
Length of Employment (type none if this does not apply):
Mortgage/Rent Payment:
Home Value:
Reference Name:           Reference Number:
Spouse Name (type none if this does not apply):
Spouse Social Security # (type none if this does not apply):
Spouse Driver's License Number (type none if this does not apply):
Spouse Birth Date (type none if this does not apply):
Spouse Work Phone (type none if this does not apply):
Spouse Employer (type none if this does not apply):
Spouse Length of Employment (type none if this does not apply):
Spouse Position (type none if this does not apply):
Spouse Monthly Income (type "0"  if this does not apply):
Spouse Previous Employer (type none if this does not apply):
Spouse Length Of Employment (type none if this does not apply):

By signing or typing my name below for this instant loan request, I authorize Citizens Community Federal to investigate, and third parties to release, information regarding  my credit rating and said credit ratings will be used as part of the criteria for approval. I certify the information provided is correct.

Sign Here:
Spouse Sign Here (type none if this does not apply):

All Applicants subject to credit approval