Dollar Finance Application

Cash Advance Application

NMLS# 2048631
Amount $ Requesting:*
Purpose of Loan:*
Referred By:
We offer referral fees, after a customer has made their first payment.
Are you Active Duty Military or a dependent?*

YesNo
Due to changes in the Military Lending Act regulations, we regret that we are no longer able to make loans to members of the Armed Forces serving on active duty or active Guard or Reserve duty or the Spouse or Dependent of such a person.
Customer Information
Title:
Name:*

First NameMiddle NameLast Name
Birth Date:

MonthDayYear
Gender:

MaleFemale
Home Phone:

Area CodePhone Number
Cell Phone:*

Area CodePhone Number
E-mail:*
Physical Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mailing Address: (if different from your physical)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How long have you lived in your given address?*

0-1 Year1-2 Years3-4 Years5+ Years
Landlord's Name (if renting):
Landlord's Phone:

Area CodePhone Number
Marital Status:*

SingleMarriedOther
Spouse's Name
Spouse's Phone:

Area CodePhone Number
Employment Information
Present Employer*
*If you are on a fixed income, please use SSI as your employer and title. Please use your personal information for the duration of the employment questions. If you have questions, please call our office during normal business hours.
Work Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone:*

Area CodePhone Number
Position/Title*
Years At Position*

Less Than 1 Year0-1 Year2-4 Years4-5 Years5+ Years
Supervisor's Name:*
Monthly Income*
Bring home or Net Pay
Pay Schedule*

WeeklyBi-WeeklyMonthly
Next Pay Date*

MonthDayYear
Date
Next Pay Date*
mm/dd
Previous Employer*
Monthly rent/mortgage*
Monthly Auto Expense*
Other Sources of Income and Amounts:
Personal References

2 Friends & 2 Family (minimum of 2)
Reference 1*

First NameLast Name
Reference 1*

Area CodePhone Number
Relationship*
Reference 2*

First NameLast Name
Reference 2*

Area CodePhone Number
Relationship*
Reference 3

First NameLast Name
Reference 3

Area CodePhone Number
Relationship
Reference 4

First NameLast Name
Reference 4

Area CodePhone Number
Relationship
Financial History
Have your ever filed Bankruptcy?*

NoYes
If yes, what year?
If yes, CH 7 or 13?
If yes, current status/last action date?
Have you had contact with an attorney to consider filing bankruptcy within the last 90 days?*

NoYes
Everything that I have stated on this form is correct to the best of my knowledge and belief. I understand that you will retain this form whether or not service is provided. I authorize you to obtain such information as you may require concerning the statements made in this application, including my income and employment history, and to obtain information about me from consumer reporting agency. I hereby authorize any third party to release any information that you may require. You are authorized to release any information requested by another party who has a legal right or to whom I may authorize to receive such information. I have provided this information for the purpose of inducing you to provide me the services offered by the company. By submitting this information, Dollar Finance, is released from any and all liability for any damages arising out of this request for service and this application, or any subsequent transaction. I have carefully read each of the answers to the foregoing questions and hereby warrant that all information provided herein is true and correct, with full knowledge that it will be relied upon by you in agreeing to provide the service for which I have requested.*

YES
Customer Signature:*

Clear
Should be Empty:

Cash Advance Application

Customer Information

Employment Information

Personal References

Financial History