DETAILS OF THE LOAN
Procedure to be financed:
Date of procedure:
Responsible doctor:
Amount to be finances:US$.00
Term:
Down payment:

PERSONAL DETAILS
Full name:
Date of birth:
Sex:
Family status:
Type of document:
Document number:
Country:
City:
Address:
Home phone:
Cell phone:
Office Tel:
Email:
Occupation:

FAMILY DETAILS
Spouse’s name:
Age: Años
Type of document:
Document number:
Cell phone:
Office tel:
Other phone:
Email:
Occupation:
Number of children: Edades:

EMPLOYMENT DETAILS
Name of the company:
Business or activity:
Position:
Length of employment:
Length of previous employment:
Current salary:
Total discounts:
Which:
Immediate superior:
Company address:
Telephone:

DETAILS OF OWN BUSINESS
Name of the company:
Line of business or activity:
Length of time in business:
Average monthly sales:
Average monthly expenses:
Number of employees:
Business address:
Telephone:

Other income:
Please specify:

PROPERTY OWNED
TYPEADDRESSMORTAGEVALUE

VEHICLES
BRANDMODELYEAR

BANK REFERENCES
TYPEINSTITUTIONBALANCE

FAMILY REFERENCES NOT LIVING WITH YOU
RELATIONSHIPNAMEADDRESSPHONE NUMBEREMAIL

PERSONAL REFERENCES
RELATIONSHIPNAMEADDRESSPHONE NUMBEREMAIL

I attest that the information herein is true and I authorize INELBAL S.A DE C.V or its delegates to corroborate it.