By submitting this information I realize that I will be forwarding my application to a U.$. Cash Advance store near me for follow up to assist in qualifying me for a payday loan. Of course there is no obligation on my part and I may call or visit a store at anytime to obtain more information or to formally apply for a loan. We are an equal opportunity lender.

 

Name *
 Maiden
 Birthdate
 Sex
Permanent Address (Include Apartment #) *
City
 State
 		Zip Code
 How Long
Previous Address (Include Apartment #)
 How Long
 Home Phone *
Phone in Whose Name? Relation:
Yourself   
Relative   
Friend   
Message Phone #
 Email Address
Living With (Check all that apply)
Spouse    Children    Parents    Friends   
Are You?
Single    Married    Divorced    Separated    Roommates   
Landlord/Mortgage Company
 Address
 Phone #
Do You?
Own    Rent    Other   
Utilities in whose name?
Do You Have A Checking Account?
Yes    No   
Do you have Direct Deposit?
Yes    No   
Bank Name
What is your approximate current checking account balance?
 How much were you looking to borrow?
Employer
 Title
 Work Phone #

Full Time    Part Time   
How Long?
 Shift
Paid:
Once a week    Once a month   
Twice a Month (Bi-Monthly)    Bi-Weekly (Every other Week)   
Other   
If Other - When?
 Day of Week Paid
Net Take Home Pay after Taxes & Withholdings
 Supervisor
Previous Employer
(if less than 1 year at current employer)
Car Information: Make
 Model
 Year
 Color
 License Plate #
Personal References
1) Name
 Address
 City, State, Zip
Phone
 Relationship
2) Name
 Address
 City, State, Zip
Phone
 Relationship
3) Name
 Address
 City, State, Zip
Phone
 Relationship
4) Name
 Address
 City, State, Zip
Phone
 Relationship
5) Name
 Address
 City, State, Zip
Phone
 Relationship
Marketing Information
How did you hear about us?
TV Ad    Radio Ad    Brochure   
Direct Mail    Newspaper Ad    Yellow Pages Ad   
Signs    Current Customer    Previous Customer   
Friend    Other    Internet/Web Page   
If other, explain:
Have you ever done a payday/cash advance with any other company before?
Yes    No   
If Yes, Where?
How far do you live from our store? (Miles)
Less than 1    2 to 3    3 to 5    Over 5   
Educational Background:
Less than High School    High School Graduate    Some College   
Trade School    College Graduate   
Total Household Income (including all wage earners in the home):

I certify the information supplied by me on this form is true and correct. I authorize verification of the truthfulness of the information contained herein, including contact with any person, or firm required to confirm this information, and fully release all parties from all liability for any damages that may result. Any false or materially misleading information provided on statements above shall be sufficient basis for credit rejection.  By submitting this no obligation, pre-determination application I acknowledge that I have read and understood the above statement and these terms.

Please call (859) 594 – 4300 approx. 10 minutes after submitting loan pre-application for follow up .

 


* Required to submit this form





 

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Ohio Check Cashing license # 700292 & Check Cashing Loan license #750233".

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