UNLV Emergency Loan Application

Emergency Loans cannot be approved without all required information completely filled out. Required items are marked with a red asterisk (*). You cannot participate in any emergency loan program unless this form is completed in full. You are applying for a LOAN.

The following error(s) was encountered:

You must provide your electronic signature [[ ]]

Student Information
Social Security Number:*	-- --
First Name:^*
Middle:
Last:^*
Driver License:	State:
College:^*
Major:^*
Credits this semester:^*
GPA:^*

Student Local Address
Address:^*
City/State/Zip:^*
Home Phone:^*
Cell Phone:
Other Phone:
Email:^*

Student Permanent Address
	[Same As Local] [Clear Fields]
Address:^*
City/State/Zip:^*
Home Phone:^*
Cell Phone:
Other Phone:
Email:^*

Employer
Company:
Supervisor:
Address:
City/State/Zip:
Main Phone:
Other Phone:
Email:
Length Employed:	Years: Months:
Monthly Income:

Other Sources of Income

Source	Monthly Income

Spouse
Name:
Employer:
Main Phone:
Other Phone:
Email:

Nearest Relative (excluding spouse)
Relationship:^*
First Name:^*
Middle:
Last:^*
Address:^*
City/State/Zip:^*
Home Phone:^*
Cell Phone:
Other Phone:
Email:

Other Reference
Relationship:^*
First Name:^*
Middle:
Last:^*
Address:^*
City/State/Zip:^*
Home Phone:^*
Cell Phone:
Other Phone:
Email:

Loan Information
Amount Requested:^*
Purpose of Loan:^*
How will you Repay Loan:^*

Electronic Signature
Certification:^*	I have read, understand and agree to be bound by the Terms and Conditions of this loan.
	I certify that all the information I have provided is true and correct.
Signature:^*	(type your full, legal name as your electronic signature)

If you need help completing this form, please contact your school.

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