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Canyon Financial, your second chance finance specialist

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Date

Amount Requested

Purpose of Loan

Referred By?

PERSONAL INFORMATION

Applicant- First Name

Last Name

Social Sec #

Date Of Birth

Phone #

Has Co-Applicant?

Co-Applicant- First Name

Last Name

Social Sec #

Date Of Birth

Phone #

Street Address
(Current Residence)

City

State

Zip Code

Length At Address?

Marital Status / #Of Dependents

Less than 3 years at current?

Previous Address (if less than 3 years at current)
(Street – City – State – Zip)

Length At Address?

Previous Address (if less than 3 years at current)
(Street – City – State – Zip)

Length At Address?

EMPLOYMENT INFORMATION (Please include 3 years of history)

Current Employer

Address

Phone

Start Date

Position

Hrs/Week

Hrly Rate

Gross Monthly Income

Net Monthly Income

Pay Schedule

Other Income

Source/Type

Previous Employer

Length Of Employment

Previous Employer

Length Of Employment

*Notice: Income from alimony, child support or separate maintenance payments need not be revealed if you chose not to have it considered.

EMPLOYMENT INFORMATION – CO-APPLICANT (Please include 3 years of history)

Current Employer

Address

Phone

Start Date

Position

Hrs/Week

Hrly Rate

Gross Monthly Income

Net Monthly Income

Pay Schedule

Other Income

Source/Type

Previous Employer

Length Of Employment

Previous Employer

Length Of Employment

*Notice: Income from alimony, child support or separate maintenance payments need not be revealed if you chose not to have it considered.

COLLATERAL

Vin#

Year

Make

Model

Trim (Lx, Ls)

Mileage

Color

Do You Owe Against This Collateral?YesNo

Idaho Title YesNo

Is The Title BrandedYesNo

Mark All Applicable:

Type Of Equipment

You have additional collateral?

REFERENCES

Name

Phone #

Relation

Name

Phone #

Relation

Name

Phone #

Relation

Name

Phone #

Relation

FINANCIAL INFORMATION

Do You Have A Checking Account? YesNo If Yes, What Financial Institution

Have You Ever Had A RepossessionYesNo If Yes, What Year What Company

Type Of Expense	Creditor	Balance	Minimum Payment	Comments
Housing Pmt/Rent
Auto Loan
Auto Ins.
Child Support
Daycare
Medical
Credit Cards
Gas Bill (Heat)
Sewer/Water/Trash
Power Bill
Cell Phone
Cable/Dish/Internet
Student Loans
Rent To Owns
Check Cashing Loans
Payday Loans
Title Loans
Federal Tax Liens
State Tax Liens
Garnishments Groceries (Food, Household Items)
Other (Explain)
Canyon Financial Proposed Loan PMT

I hereby authorize the lender/ Broker to verify my past and present employment earnings records, bank accounts, stock holdings, and any other asset balances that are needed to process my loan application. I further authorize the Lender/ Broker to order a consumer credit report and verify other information, including past and present mortgage and landlord references. It is understood that a copy of this form will also serve as authorization. The information the Lender/ Broker obtains is only to be used in the processing of my application for a loan.

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