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    Loan Application


     CUSTOMER INFORMATION
    First Name:  
    Last Name:  
    E-Mail:  
    Date Of Birth:  
    Home Phone:  
    (xxx-xxx-xxxx)  
    Fax Number:  
    (xxx-xxx-xxxx)  
    SSN#:    -  -
    How did you hear about us?
    Address:  
    Apt:  
    City:  
    State Zip
    How long at this address?
    Yrs. Mos.

    Drivers     License  
     State:  

    License #: 

    Loan Amount: 


     EMPLOYER INFORMATION
    Job Title:  
    Work Phone: 
    (xxx-xxx-xxxx)     		  X
    Supervisor  
     Name:  

    Supervisor    Phone:               (xxx-xxx-xxxx)   

    		  X
    Employer Name:  
    Address 1:  
    Address 2:  
    City:  

    State Zip


     PAYROLL INFORMATION
     
    Type of employment:   
    Have you recently filed or are you   
    planning to file for bankruptcy?   
    How do you receive your paycheck?   
    How often do you receive a paycheck?   
    Gross pay per paycheck*:    $  .00
    *or other sources of income periodically deposited to your account. However, alimony, child support or, separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.
    Your Last Pay Date:   
    Your Next Pay Date:  
     These MUST be accurate to calculate your loan
    (Pay dates can not be on Holidays, Weekends or any other Non-Banking Day)

     BANK INFORMATION
    Picture of align check
    Bank Name:  
    Account Type:  
    ABA Number:  
    Acct. Number:  

     REFERENCE INFORMATION
    Please supply 2 contacts, one must be a relative NOT living with you.
    We WILL NOT CONTACT any of your personal contacts to qualify your loan.
    Personal Contact #1
    First Name:  
    Last Name:  

    Phone Number:(xxx-xxx-xxxx)  
    Relationship:  
    Personal Contact #2
    First Name:  
    Last Name:  

    Phone Number:(xxx-xxx-xxxx)  
    Relationship:  

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