4 Enter date of birth. applicant’s Date of Birth 5 Enter the home, cell, and business telephone number, as applicant’s Contact applicable. Telephone Numbers Indicate applicant's best contact telephone number by selecting "Primary" in the applicable box. 6 Check applicable citizenship status. If non-citizen national, qualified Citizenship alien, or refugee, as defined by the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA), 8 U.S.C. 1641, applicant must provide copies of appropriate documentation of immigration status, including and not limited, to a current I-551, Naturalization Certificate, or I-688B. 7 Check the appropriate box indicating race. More than one applicant’s Race box may be checked. Providing race is voluntary; however, applicant’s if applying as a socially disadvantaged applicant based on race, this information is required. 8 Enter the name, address and telephone number of the applicant’s Name and employer, if applicable. Address of Employer 9 Check the appropriate box indicating veteran status. applicant’s Veteran Status 10 Check the appropriate box indicating ethnicity. Providing applicant’s Ethnicity ethnicity is voluntary; however, if applying as a socially applicant’s disadvantaged applicant based on ethnicity, this information is required. 11 Check the appropriate box indicating gender. Providing applicant’s Gender gender is voluntary; however, if applying as a socially applicant’s disadvantaged applicant based on gender, this information is required. 12 Check the appropriate box indicating if information collected was For FSA Use provided or observed. Only 13 Enter the exact full legal name as shown on a state driver's applicant’s Exact Full license or State ID card. Legal Name 14 Enter the email address. applicant’s Email Address 15 Enter social security number (9-digit number) applicant’s Social
4 Date of Birth Enter applicant’s date of birth. 5 Contact Telephone Numbers Enter the applicant’s home, cell, and business telephone number, as applicable. Indicate applicant's best contact telephone number by selecting "Primary" in the applicable box. 6 Citizenship Check applicable citizenship status. If non-citizen national, qualified alien, or refugee, as defined by the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA), 8 U.S.C. 1641, applicant must provide copies of appropriate documentation of immigration status, including and not limited, to a current I-551, Naturalization Certificate, or I-688B. 7 Race Check the appropriate box indicating applicant’s race. More than one box may be checked. Providing applicant’s race is voluntary; however, if applying as a socially disadvantaged applicant based on race, this information is required. 8 Name and Address of Employer Enter the name, address and telephone number of the applicant’s employer, if applicable. 9 Veteran Status Check the appropriate box indicating applicant’s veteran status. 10 Ethnicity Check the appropriate box indicating applicant’s ethnicity. Providing applicant’s ethnicity is voluntary; however, if applying as a socially disadvantaged applicant based on ethnicity, this information is required. 11 Gender Check the appropriate box indicating applicant’s gender. Providing applicant’s gender is voluntary; however, if applying as a socially disadvantaged applicant based on gender, this information is required. 12 For FSA Use Only Check the appropriate box indicating if information collected was provided or observed. 13 Exact Full Legal Name Enter the applicant’s exact full legal name as shown on a state driver's license or State ID card. 14 Email Address Enter the applicant’s email address. 15 Social Enter applicant’s social security number (9-digit number)
FSA_2001_Instructions_Loan_Application_Form.docx