First Name

Last Name

Email

Social Security Number

Birth Date (MM/DD/YYYY)

Street Address

City

State

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Main Phone

Secondary Phone

Gross Monthly Income $

Are you self employed?

Admissions Counselor

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  Wingate   WayPoints  

I am authorizing Clark Educational Loans to obtain a credit report to see if I pre-qualify for student loans. I understand that this is a pre-qualification form and not a complete loan application. I have read the statement below regarding consent and authorization to obtain consumer reports.

Initial Here for Authorization

I understand that (1) consumer reports (credit reports) may be obtained in connection with my Loan Application, (2) if I request, I will be informed whether or not consumer reports are obtained, and (3) if reports are obtained, if I request, I will be informed of the names and addresses of the consumer reporting agencies (credit bureaus) that furnish the reports. If this application is approved, subsequent consumer reports may be requested or used in connection with an update, renewal, or extension of the credit for which I have applied. I (we) have completed this application to obtain credit, and certify that the above statements are true and complete. I (we) authorize Clark Custom Educational Loans, Inc. to check my (our) credit references and to obtain credit report(s). I (we) also authorize Clark Behavioral Health Financing, Inc. to provide credit report(s), personal and financial information provided with this application and credit mortgage information arising from this transaction to the school listed above. I (we) authorize the school listed above to release to the lending institution , subsequent holder or their agents, any requested information pertinent to this loan application (e.g. employment, enrollment status, prior loan history, current address). I certify that the proceeds of this loan will be used for educational purposes at the educational institution listed on this application. See your Promissory Note for notices to California, Ohio and Wisconsin residents. Even if I (we) have elected to opt out of information sharing or do so in the future, I (we) understand and agree this consent authorizes Clark Behavioral Health Financing, Inc. to share this information for purposes of processing this application and servicing any resulting loan. PLEASE TYPE YOUR FULL NAME AS YOUR SIGNATURE

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