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Personal Information

Loan Amount: *
Name: *
Gender: *
Address: *

Housing Status: *
Duration at Address:
Email: *
Date of Birth: *
Home Phone: *
Cell Phone: *
Preferred Contact Time: *
Social Security Number: *
Drivers License State: *
Drivers License No: *
Military Status:

Warning: It is important to fill out this form accurately. Knowingly making a false statement on a credit application is a crime


Income Information

Income Type: *
How do you receive your income? *
Income amount per pay period: *
How often do you receive income? *
Last Income Date: *
Bank Name: *
Account Type: *
ABA (Routing) Number: *
Account No: *
Account Open Since:

Employer Information

Employer Name: *
Employer Address: *
Employment Type: *
Job Title: *
Work Phone: *
Hire date: *
Duration with current employer: *


Reference Information

Please list 2 References. One must be a relative NOT living with you.

Reference 1:
Contact Phone Number: *
Relationship: *
Reference 2:
Contact Phone Number: *
Relationship: *

Please be patient after submitting your application, processing could take as much as five minutes.

Niizh, LLC reviews your information in real-time to determine whether your information meets our lending criteria. Niizh, LLC may, among other things, verify your social security number, perform a credit check, and review your information against national databases (such as Clarity and/or DataX) that tracks consumer transactions with lending institutions. In addition, we perform other verification checks including, but not limited to, recent banking activity, employment status, and accuracy of application data.

By submitting the application form(s), you agree to allow Niizh, LLC to review, verify, and research your information in such manner.