Online Loan Application

Please complete ALL questions. Failure to do so may delay processing.
WARNING: Any person who knowingly makes a false statement or misrepresentation on this Application/Promissory Note is subject to penalties which may include fines or imprisonment under the United States Criminal Code.
Please be sure using our secure server. You should see a yellow/gold lock at the bottom of your browser. Click it to verify our secure certificate.

• You are not using the secure server!
• [ TAKE ME TO THE SECURE CLARK LOAN APPLICATION. ]

Form Navigation

• Mouse: Just click on any field and begin typing.
• Keyboard: Use TAB to go through the form and use the SPACEBAR to select the radio buttons.
• Click the SUBMIT button at the bottom when you are finished.
• NOTE: only press ENTER when you are completely finished! (Pressing ENTER will submit the form.)

PARTICIPANT INFORMATION
First Name
Middle Name
Last Name
Social Security Number
Grade Level
Date of Birth	Month 1 - January 2 - February 3 - March 4 - April 5 - May 6 - June 7 - July 8 - August 9 - September 10 - October 11 - November 12 - December Day 12345678910111213141516171819202122232425262728293031 Year 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
SCHOOL/PROGRAM INFORMATION
School/Program Name
Address
City
State
Zip
Estimated Completion Date	Month 1 - January 2 - February 3 - March 4 - April 5 - May 6 - June 7 - July 8 - August 9 - September 10 - October 11 - November 12 - December Day 12345678910111213141516171819202122232425262728293031 Year 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
LOAN INFORMATION
Requested Amount
Enrollment Begin Date	Month 1 - January 2 - February 3 - March 4 - April 5 - May 6 - June 7 - July 8 - August 9 - September 10 - October 11 - November 12 - December Day 12345678910111213141516171819202122232425262728293031 Year 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Enrollment End Date	Month 1 - January 2 - February 3 - March 4 - April 5 - May 6 - June 7 - July 8 - August 9 - September 10 - October 11 - November 12 - December Day 12345678910111213141516171819202122232425262728293031 Year 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
APPLICANT INFORMATION
First Name
Middle Name
Last Name
Social Security Number
Driver's License Number
Driver's License Expiration Date
Date of Birth	Month 1 - January 2 - February 3 - March 4 - April 5 - May 6 - June 7 - July 8 - August 9 - September 10 - October 11 - November 12 - December Day 12345678910111213141516171819202122232425262728293031 Year 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Address
City
State
Zip
Cell Phone
Home Phone
Business Phone
Fax Phone
Email Address
Citizenship	U.S. Citizen or National Eligible non-citizen or Permanent based resident
Number of Dependents in the previous tax year	0 1 2 3 4 5 6 7 8 9 10 or more
HOUSING
Housing situation	Rent Own Other
Current Home Value (if applicable)
Mortgage Holder (if applicable)
Total monthly rent or mortgage payment(s) (include home equity)
Time at current residence
List ALL addresses in the past 5 years
1ST PERSONAL REFERENCE (applicant)
First Name
Last Name
Address
City
State
Zip
Phone Number
2ND PERSONAL REFERENCE (applicant)
First Name
Last Name
Address
City
State
Zip
Phone Number
APPLICANT EMPLOYMENT
Job title/Occupation
Employer
Time at current job
List prior employment history for 5 years
Employer Address
Employer City
Employer State
Employer Zip
Employer Phone
Are you self employed?	No Yes
APPLICANT INCOME
What is your gross monthly employment income?
Other monthly income?
Have you ever DEFAULTED on a student loan?	No Yes
Have you ever declared BANKRUPTCY?	No Yes
What is your total EDUCATIONAL LOAN Debt? (if any)
CO-APPLICANT INFORMATION
First Name
Middle Name
Last Name
Social Security Number
Driver's License Number
Driver's License Expiration Date
Date of Birth	Month 1 - January 2 - February 3 - March 4 - April 5 - May 6 - June 7 - July 8 - August 9 - September 10 - October 11 - November 12 - December Day 12345678910111213141516171819202122232425262728293031 Year 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Address
City
State
Zip
Cell Phone
Home Phone
Business Phone
Fax Phone
Email Address
Citizenship	U.S. Citizen or National Eligible non-citizen or Permanent based resident
Number of Dependents in the previous tax year	0 1 2 3 4 5 6 7 8 9 10 or more
CO-APPLICANT HOUSING
Housing situation	Rent Own Other
Current Home Value (if applicable)
Mortgage Holder (if applicable)
Total monthly rent or mortgage payment(s) (include home equity)
Time at current residence
List ALL addresses in the past 5 years
1ST PERSONAL REFERENCE (co-applicant)
First Name
Last Name
Address
City
State
Zip
Phone Number
2ND PERSONAL REFERENCE (co-applicant)
First Name
Last Name
Address
City
State
Zip
Phone Number
CO-APPLICANT EMPLOYMENT
Job title/Occupation
Employer
Time at current job
List prior employment history for 5 years
Employer Address
Employer City
Employer State
Employer Zip
Employer Phone
Are you self employed?	No Yes
CO-APPLICANT INCOME
What is your gross monthly employment income?
Other monthly income?
Have you ever DEFAULTED on a student loan?	No Yes
Have you ever declared BANKRUPTCY?	No Yes
FEEDBACK, NOTES, QUESTIONS and/or COMMENTS
FEEDBACK, NOTES, QUESTIONS, CONCERNS and/or COMMENTS
TERMS AND CONDITIONS
Terms and conditions (You must AGREE, or we will not process your application.)	I AGREE to the terms and conditions I do NOT agree - do NOT process this application
Please[ PRINT THIS APPLICATION ]  for your records.
By accepting the I agree box above you are authorizing Clark Custom Educational Loans, Inc. d.b.a. Clark Behavioral Health Financing (hereafter referred to as “Clark”) to check my credit references and to obtain and use consumer reports (i.e. credit reports) on my credit history in connection with my Loan Application and in connection with any update, renewal or extension of credit for which I have applied. If I request, I will I will be informed whether or not consumer reports are obtained, as well as the names and addresses of the consumer reporting agencies (i.e. credit bureaus) that furnish the reports. I further authorize Clark to provide information regarding the status of my transaction to the Facility identified above in item 3 of this Loan Application. I authorize that Facility to release to Clark, the lending institution, its agents, subsequent holder of the loan and its agents, any requested information pertinent to this Loan Application, including but not limited to, employment, enrollment status, prior loan history and my current address. I agree to refer to my Promissory Note for notices to California, Ohio and Wisconsin residents. Even if I have elected to opt out of information sharing or do so in the future, I understand and agree that this consent authorizes Clark to share my information for purposes of processing this Loan Application and servicing any resulting loan. I have completed this Loan Application to obtain credit and, by signing above, certify that the above statements are true and complete.