Lending Circles Registration Form

First Name *

Last Name *

Street Address *

City *

State *

Zip Code *

Phone Number *

Alt Phone

Email Address *

Birth Date *

Highest Education Level *

Marital Status *

Resident Status *

Demographic *

Are you a U.S. Veteran? *

Employment Status *

Annual Income *

Name of Employer *

Position *

Number of years and months at current position *

Are you a single parent (head of household) financially supporting at least one child? *

Language Preference *

English

Spanish

Other Other

Current Residence *

I rent

I have a mortgage

Monthly rent or mortgage payment Monthly rent or mortgage payment

Number of people in your household including yourself *

ATTENTION PLEASE READ FOR NEXT SECTION: The following chart is to disclose total income for all INDIVIDUALS CONTRIBUTING FINANCIALLY IN THE HOME. It is not necessary to list dependents who do not contribute financially.

Note: While the chart appears to be split into two sections please answer by row for each person.

* Income - in this field please type the monthly income for this individual

	Name	Age	* Income
1	Name	Age	* Income
2	Name	Age	* Income
3	Name	Age	* Income
4	Name	Age	* Income
5	Name	Age	* Income
6	Name	Age	* Income
7	Name	Age	* Income

	Income type		Gender		Disability		Relation
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How did you hear about us? Select any and all that apply. *

Please give the reason you are signing up for a lending circle. *

Need to improve my credit score

Need to save for down payment on a home

Need to save for my small business

Other, explain and be specific! Other, explain and be specific!

Emergency contact first and last name *

Emergency contact phone *

Emergency contact relationship *

Please Sign *

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