Application for Cash Advance from AmeriCash.

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Notice: A short term advance provides the cash needed to meet an immediate short-term cash flow problem. It is not a solution for longer term financial problems for which longer term financing may be more appropriate. You may want to discuss your financial situation with a nonprofit counseling service in your community. You will be charged additional fees if you renew/extend the advance.

NEW CUSTOMER APPLICATION

CUSTOMER INFORMATION

Your First Name
Middle Name or Initial
Your Last Name
Specify if JR. , SR. , II , III etc.
Your personal e-mail address (You must have an active personal email address. This is how we contact you with approval information.)
Date of Birth (mm/dd/yy)
Residence Phone (with area code)
Cellular or Moble Phone number
Your Residence Address (including apt.# if applicable) No P.O. Boxes
city	state zip code
Do you rent or own?	RENT OWN
How many months have you lived at this residence?
Social Security Number
Driver's license number
State drivers license was issued
fax number
Spouse's Name (if married)
Spouse's Social Security Number
How many advances with other providers do you currently have?

EMPLOYMENT INFORMATION

Name of current Employer (company name)
Employer's phone number (include area code)
Employer's Address
city	state zip code
Your Work Dept. / Job Function
Your phone number at work . (include area code/extensions)
Name you go by at work (i.e./nickname)
Months with current employer
Monthly net (take home) income by direct deposit.
Is your income currently being garnished for any reason?	YES NO

How often each month does your employer directly deposit your paycheck?

Every Week or Every other Week or Twice per Month

If Weekly or Every other Week, SPECIFY which day of the week

If Twice per month, SPECIFY which 2 dates during the month and
(example: 1st and 15th)

Your NEXT TWO pay dates by direct deposit.

//2001 Month by number / Day /Year

Please make sure the items above are filled in correctly to accurately reflect your actual direct deposit dates so we can complete your application process without delays.

How did you hear about AmeriCash Advance?

Search engine A Friend

Thrifty Nickel Other

If you were referred by someone, please enter their full name.

If you found us by a search engine/search directory please list which one.

If "other" please specify..

WORK SUPERVISOR INFO (if Military NCOIC or Commanding Officer information)

Name (first/ last)
Supervisor's title
Supervisor's Work Phone number (area code and extension)
Work e-mail address

NEAREST RELATIVE NOT LIVING WITH YOU

Name of Relative
Physical Address
city	state zip code
Residence Phone (with area code)
Relationship (brother, aunt ,etc.)

PERSONAL REFERENCES

(Must be non-relatives)

Name

Phone number

Relationship

BANK INFORMATION FOR CASH ADVANCE TRANSFER

Enter your name and address exactly how it appears on your checks.

(first)

(middle name/ initial if used)

(last)

Your Address
City
State
Zip
Name of bank
Bank phone number
Transit Routing number (located on bottom of your check)

Bank Account Number (located on bottom of your check)
How many months have you had this account?

( EXAMPLE CHECK)

To Receive Your First Cash Advance Upon Approval

Mother's Maiden Name Today's date

The amount I am requesting for my first advance is

Due date: Date of your NEXT direct deposit pay day: (up to a maximum 15 days)

mm/dd/yy

UPON APPROVAL, I authorize AmeriCash Advance LLC to deposit a cash advance (in the amount that I will be approved for, which I acknowledge may be less than the amount requested) into my bank account and to withdraw the approved advance amount plus the associated fee at the rate of $20 per $100 advanced to me, on the date specified above. I understand and agree the cash advance amount received plus fee is due on my NEXT NEAREST PAY DATE (up to a maximum of 15 days). I agree this authorization may not be revoked by me until the approved amount of this transaction is paid in full.

I agree to maintain an adequate balance in my account(s) and keep it open to allow all payments to AmeriCash Advance by EFT/ACH to occur in a timely manner for the scheduled due date. If the payment is returned for ANY reason, I agree that I will also pay a $25.00 return fee.

I acknowledge all such transactions are made pursuant to the Master Cash Advance Agreement, and will be on file with AmeriCash Advance. All applications are subject to approval at 901 Market Street, Wilmington, DE 19801.

I understand I will be contacted by phone at the numbers provided on this application to confirm my approved cash advance amount.

I understand and agree. (Please type your signature and continue)

Legal/Disclosure Acknowledgement: If you acknowledge that you have read the disclosures listed in the Master Agreement, verify by clicking the yes button below to continue. You may review these documents again by clicking here :Master Agreement (disclosures) (to return to this page after reviewing, simply click your back button)

I have read, understand, and agree to ALL terms, disclosures, and conditions of the AmeriCash Advance Internet Master Cash Advance Agreement.

(MUST CHECK ONE!) YES    NO

By electronically signing this form I acknowledge that all information provided by me in this application is true and correct and authorize AmeriCash Advance LLC, its successors, and assigns, to verify any and all information contained herein. I am not now presently involved in, nor do I contemplate a bankruptcy proceeding in the future. I furthermore authorize AmeriCash Advance to conduct the EFT transactions requested now and in the future, according to all agreements and disclosures listed.

Type your Social Security Number

Type your name as your electronic signature.

For your records, print a copy of your completed application BEFORE submitting.

   Click to SUBMIT your information for processing. You will then view a reminder to fax to us your most recent two bank statements.

(Click here to DELETE the information above)

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