T _ O_ O _ L___ K_ I _ T

IV APPLICATION

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PERSONAL INFORMATION	______________________________
Name of Applicant	______________________________
Home Address	______________________________
Business Location	______________________________
National I.D. Number	______________________________
Age	______________________________
Gender	______________________________
Highest Level of Education Reached	______________________________
ECONOMIC ACTIVITY OF THE BORROWER	______________________________
What is your main income activity?	______________________________
How long have you been doing it?	______________________________
How many months a year?	______________________________
How many hours per day/week do you do this activity?	______________________________
Where do you do this activity?	______________________________
Describe your products or services.	______________________________
What are your sales on a good day?	______________________________
..on a slow day?	______________________________
..on a regular day?	______________________________
What is your average monthly income from this activity?	______________________________
Do you pay anyone outside your household to help you? How many and how much do you pay them?	______________________________
What are your average monthly expenses (materials)?	______________________________
What plans do you have for your activity in the future?	______________________________
ECONOMIC ACTIVITY OF THE HOUSEHOLD	______________________________
How many people are there in your household?	______________________________
Do your family members help?	______________________________
In your household, what are the different activities conducted by all members? Please stipulate frequency and estimated income.	______________________________
CREDIT	______________________________
How will you use your loan?	______________________________
How much do you want to borrow?	______________________________
What is the loan term?	______________________________
From what other sources have you borrowed money?	______________________________
How many times have you borrowed before from this project?	______________________________
Were your payments on time or sometimes late?	______________________________
Did you experience difficulties in paying back your loan? If yes, why?	______________________________
ASSETS/SAVINGS	______________________________
How much do you have in savings (cash and in-kind)?	______________________________
Where are the savings located?	______________________________
Do you own land? How much? Is it arable?	______________________________
What equipment used for your economic activity do you own?	______________________________
APPROVAL	______________________________
The Field Agent must read aloud the loan guarantee to each member of the Credit Group.	We, by signing below, agree that we are responsible for the payment of any and all principal and interest owed by this applicant to [Organization name]. If the borrower cannot or will not repay a loan, we agree to make the payments and understand that we are not eligible for any new loans until all outstanding debts of the borrower to [Organization name] are paid in full.
signed:	signed:
signed:	signed:
signed:	signed:
Field Agent verifies information is accurate	signed:
SUMMARY	______________________________
Loan Amount	______________________________
Loan Term	______________________________
Interest Rate Per Month	______________________________
Loan Payment	______________________________
Frequency	______________________________

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