Loan Application Form - Clark Public Utilities

Loan Applicant Information

Would you like to add a co-applicant to this application?*

Yes
No

Name*

First Last

Date of Birth*

Social Security Number*

Why do you need my SSN? Social Security Numbers (SSN) are required to run credit reports on each applicant. This website is encrypted and secure. If you do not have a social security number or do not want to provide your SSN on this electronic application, call Energy Services at 3355 for a paper application which you can fill out and submit in person at one of our office locations.

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Email Address*

Phone Number*

Alternate Phone Number

Duration at current address*

Years*

Months*

Have you lived at your current address for less than 2 years?*

Yes
No

Previous Address*

Street Address Address Line 2 City State ZIP Code

Previous Electric Utility*

Employer*

Employment Length*

Years*

Months*

Length of Employment

Gross monthly income:*

Please include proof of income:*

For example: The last two current pay stubs or last year's tax return (if self-employed).

Drop files here or

Safety & Outages

Eligibility

Loan Applicant Information

Co-Applicant Information

Property Information

Certification & Authorization

Safety & Outages