NewCustomerApplication

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 counseling service in your community. You will be charged additional fees if you renew/extend the advance.

NEW CUSTOMER ADVANCE APPLICATION - SSL SECURED PAGE

NOTICE: If you currently have a cash advance/payday loan with, or have submitted application with MORE than one other cash advance lender, we will not be able to approve your application.

CUSTOMER INFORMATION

Social Security Number

Your Personal E-Mail Address (must have a valid email address)
First Name
Middle Name
Last Name
Date of Birth (mm/dd/yy)
Mother's Maiden Name
Home Phone (w/area code)
Cell Phone Number
Your Residence Address *NO PO BOXES*
Apt #
City State
Zip
RENT OWN Months at address
Driver's license number State Issued
Fax number
Spouse's Name (if married)
Spouse's Social Security #

If you have other advances or loans with other providers, what is the amount owed?
Are you presently involved in or contemplating bankruptcy proceedings in the future?

EMPLOYMENT INFORMATION ( We must be able to contact you by phone at your place of employment)

Name of Current Employer
Employer's Phone #
Employer's Address
City State
Zip
Your Phone # at Work EXT
Name at Work (or nickname)
Email address at work
Length of employment
Supervisor's Name
Supervisor's Phone EXT
Monthly net (take home) income
ARE YOU PAID BY DIRECT DEPOSIT FROM YOUR EMPLOYER?
What are your scheduled pay dates?
If weekly or bi-weekly, what day?

/ / Month by number / Day

Your NEXT TWO pay dates.
Please make sure these dates are filled in correctly to reflect your actual pay dates so we can complete your application process without delay.

HOW DID YOU HEAR ABOUT AMERICASH ADVANCE?

Search engine A Friend Other
If you were referred by someone, please enter their full name
If you found us by a search engine please list which one.
If "other" please specify.

PERSONAL REFERENCES

Name	Phone	Relation
Name	Phone	Relation
Name	Phone	Relation

BANK INFORMATION FOR CASH ADVANCE TRANSFER

Name of bank
Bank phone (w/area code)
Transit Routing Number
Bank Account Number
Bank Routing and Account Numbers are located on the bottom of your personal check.
Months account open

To Receive Your First Cash Advance Upon Approval

The amount I am requesting for my first advance.

mm/dd/yy

Due date: Your next pay date (up to a maximum 15 days)

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 $25 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 understand I will be contacted by phone at the numbers provided on this application to confirm my approved cash advance amount.

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) I agree that electronic mail, electronic forms, records, photocopies, and /or facsimile copies of the documents I submit are valid and enforceable as the original. I agree that by typing my name as my electronic signature, it is acknowledged and understood that it constitutes an acceptance of all terms and conditions of the master cash advance agreement and is valid and enforceable in accordance with the "Electronic Signatures in Global and National Commerce Act"

I agree to maintain an adequate balance and keep my account(s) open to allow all ACH/EFT and/or bank drafts to AmeriCash Advance to occur in a timely manner for the scheduled due date. I further agree and confirm that by submitting completed/ signed americashadvance.com internet request forms as a matter of convenience, hereby constitutes the same legal and binding document as providing AmeriCash Advance LLC with my personal post dated check, in the amount of the cash advance plus associated fees. If the payment is returned for ANY reason, I agree that I will also pay a $25.00 return fee. I agree that upon submission of my electronic signature, I am not presently involved in, nor contemplating bankruptcy proceedings now or in the future.

I understand, acknowledge, and fully agree that, upon approval, this and all future transactions are made pursuant to the AmeriCash Advance Internet Master Cash Advance agreement (which will be on file with AmeriCash Advance) and is NOT an installment loan that I can make payments on, but is due in full on my next nearest pay date.

I have read, understand, and agree to ALL terms, disclosures, and conditions of the AmeriCash Advance Internet Master Cash Advance Agreement.     (MUST SELECT ONE!)

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. Furthermore, I authorize AmeriCash Advance to conduct the EFT transactions and/or bank drafts requested now and in the future, according to all agreements and disclosures listed.

TYPE YOUR NAME AS YOUR ELECTRONIC SIGNATURE

Social Security Number

Any additional comments, type here:

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

   Click to SUBMIT your information for processing.

(You will then view the page to PRINT, SIGN, and FAX with the required verification items)

           (Click here to DELETE the information above)

(If you experience any problems in submitting this application -please call 1-877-369-6700 and leave a detailed message of what occurred. Thank you!)

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