Consumer Loan Application Form

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* = mandatory field
I hereby apply for a loan, with all charges added to be repaid in monthly instalments beginning: (dd/mm/yyyy)
Personal Information
My Coupon Number
Branch*
Amount Of Loan*
Purpose of Loan*
Full Name* First Middle Last
Social Security Number*
Date of Birth (dd/mm/yr)*
Home Address*
Years There
Business Phone*
Email Address*
Home Phone/ Cell Phone*
Marital Status*
Spousal Information (If Applicable)
Number of Dependents (Include Spouse) *
Name of Spouse First Middle Last
Social Security Number of Spouse
Landlord Information (If Applicable)
Name of Landlord (if renting) First Middle Last
Address of Landlord
Neartest relative with whom not living (if none give other reference plus telephone/cell number)
First Contact Person's Name* First Middle Last
Address*
Telephone/cell No.(s)
Relationship*
Second Contact Person's Name* First Middle Last
Address*
Telephone/cell No.(s)
Relationship*
Employment Information
Full Name of Employer
Address of Employer
Years There
Occupation*
Badge or Employment #
Full Name of Previous Employer
Years there
Full Name of Spouse's Employer (if applicable)
Address of Spouse's Employer
Years there
Statement of Assets and Liabilities
Assets
Cash*
Life Insurance Company (name)
Insured Amount  
Cash Surrender Value
Motor Vehicles (see particulars below)*
Other Assets Not Listed Elsewhere
(e.g-inventories, stocks, goods for re-sale)*
Real Estate (see particulars below)*
Other Assets
Totals
I hereby certify that I am not undergoing any medical attention and that within the past 12 months I have not been hospitalized. I further confirm that I am not suffering from any medical attention and that within the past 12 months I have not been hospitalized. I further confirm that I am not suffering from any serious ailment. I acknowledge by my signature that the Bank is not liable to pay out my debt upon death if knowingly I misinformed the Bank. I further acknowledge that the Bank is not liable to pay off my debt if my loan is in arrears 90 days or more.
I agree*
Details of Real Estate if any, including location, Market Value and all Encumbrances.
  REAL ESTATE (Location) MARKET VALUE ENCUMBRANCES
1.*
2.
3.
4.
Have you borrowed in the past from this or any other branch?*
I warrant and confirm that the information given herein is true and correct and I understand clearly that it is being used to determine my credit responsibility. I further confirm that no information which might affect the Bank's decision to make the loan has been withheld. You are authorized to obtain any information you may require relative to this application from any source to which you may apply and each source is hereby authorized to provide you with such information. You are also authorized to retain the application whether or not the relative loan is approved. My deposit account may be charged with the monthly payment as they mature and I agree to pay your customary assessment for any notices of overdue installments.
I agree*

I hereby consent to you establishing a policy under the Belize Bank's Consumer Loan Debt Cancellation Scheme and loss if any payable to The Belize Bank Ltd. This Scheme is to be effective as from the date on which the loan is made and on such terms and conditions as may be agreed between I and the Bank but coverage is not to exceed the principal amount of the Consumer Loan. I expressly agree to pay the rate of discount which shall not exceed 13.50% per annum per $100.00 on the full net proceeds of the loan.
I agree*
Monthly Family Budget Analysis
INCOME
 
  Amount in BZD
1) Gross Monthly Income*
2) Less - Deductions at source*
3) Net take home pay
4) Spouse's monthly income
(Add 20% of spouse's income)*
5) Other (specify)
6) Total net monthly income
EXPENDITURES
 
7) Shelter Monthly Amount (omit cents)  
a) Maintenance & Repairs on Property
b) Rent
c) Property Insurance (If Applicable)
d) Elecricity
e) Telephone
f) Water
g) Cable TV (If Applicable)
  Total
8) Transportation  
a) Vehicle license (If Applicable)
b) Vehicle insurance (If Applicable)
c) Vehicle - operating expenses (If Applicable)
d) Public Transportation (If Applicable)
  Total
9) Living Expenses  
a) Food*
b) Clothing
c) Medical & Dental
d) Life Insurance Premium
e) Entertainment & Social
f) Other (specify)
  Total
10) Installment Obligations Balances  
a) BelizeBank Limited (Consumer Loan)
b) Alliance Loan
c) Atlantic Loan
d) Scotia Loan
e) FCIB Loan
f) DFC Loan
g) Credit Union (name)
h) Courts Belize
i) Credit Card (name)
j) Credit Card (name)
k) First Mortgage Loan (name)
l) Second Mortgage Loan (name)
  Total
11) Monthly Savings
12) Total Monthly Commitments
13) Residue
14) Gross Commitments/Income(%)
Security Code