123 Cash Payday Loans

Click here for Printable English Application. Online Application
Name:
Address:
City State:
E-mail:
How long at residence?
Type of Residence:
If rented Landlord Name and Phone #
Select type:
Home phone Number:
Cell Phone Number:
Employment Information
Employer :
Employer address:
Employer phone Number:
Job title/ Department:
Hire date:
Supervisor:
Employment status:
If retired are you on Social Security?
What day of the week do you get paid?
How often do you get paid?
What is your take home pay?
Do you have direct deposit
Personal References(two must be relatives)
Reference 1
Name:
Relationship:
Address:
Phone Number:
Reference 2
Name:
Relationship:
Address:
Phone Number:
Reference 3
Name:
Relationship:
Address:
Phone Number:
You have the following (3) payment options for your payday loan. 1. Payoff your loan by either mailing us a Money Order for the full amount or have us ACH your checking account to payoff the loan. 2. Pay your finance charge and extend your loan until your next pay period. You still owe the original amount advanced to you, plus the fee at the end of your new due date. Only (4) extensions are allowed then your account must be paid in full. 3. In addition to paying the finance charge, any extra amount paid will be applied towards principle due and new loan documents will be calculated based on the new principle amount due. I certify the information supplied by me on this form is true and correct. I authorize verification of the truthfulness of all information contained herein, including contact with any person or firm listed above, and fully release all parties from all liability for any damage that may result. Any false statement made above shall be sufficient basis for rejection. I have read and understand the above statement.
Your Initials:

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