Horn Lake Application

1
How Much Would You Like to Borrow?* This field is required.Choose an Amount
$100
$25
$50
$75
$100
$125
$150
$175
$200
$225
$250
$275
$300
$325
$350
$375
$400
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Name* This field is required.FIRST MIDDLE LAST
3
Address* This field is required.
Street Address
Street Address Line 2
City
Please Select
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Cell Number
5
Work Number
6
Home Number
7
Employer or Other Income Source* This field is required.Name of Company or Issuer
8
Start Date* This field is required.Approximate Date of Hire or Initial Disbursement of Funds
Date
Month
Day
Year
9
Pay Frequency* This field is required.Choose one
WEEKLY
BI-WEEKLY
BI-MONTHLY
MONTHLY
10
Which Day of the Week Do You Get Paid?Choose from the dropdown menu
SUNDAY
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
11
What Day of the Month Do You Get Paid?Choose all that apply.
EOM
15TH
1ST
3RD
1ST WED
2ND WED
3RD WED
4TH WED
OTHER
12
Do You Get Paid on the 15th and End of the Month or Other?Choose one (if other fill out the dates in the field marked "OTHER").
Please Select
Please Select
15/EOM
OTHER
Choose One
OTHER
13
Take Home Pay* This field is required.Total income per pay period.
14
Do You Have any other Income You Would Like Us to Consider?
Please Select
Please Select
Yes, I have other income to consider.
No, I have entered all of my income.
MAKE A SELECTION
ENTER SOURCE & AMOUNT OF OTHER INCOME
15
Personal Information* This field is required.Your information will remain secure and confidential.
Social Security Number
Date of Birth
ID or DL Number
Email Address
16
Have You Ever Filed Bankruptcy?* This field is required.Answer truthfully.
Please Select
Please Select
YES, Chapter 7
YES, Chapter 13
NO
MAKE A SELECTION
Please Select
Please Select
I AM NOT CURRENTLY UNDER BANKRUPTCY
I AM CURRENTLY UNDER BANKRUPTCY
MY CASE HAS BEEN DISMISSED
MY CASE HAS BEEN DISCHARGED
STATUS (choose one / view all options)
17
DOD IDENTIFICATION OF COVERED BORROWER STATEMENT* This field is required.Federal law provides important protections to active duty members of the Armed Forces and their dependents. To ensure that these protections are provided to eligible applicants you are required to choose one of the following:
I AM NOT a regular or reserve member of the Army, Navy, Marine Corps, Air Force, or Coast Guard, serving on active duty under a call or order that does not specify a period of 30 days or fewer (or a dependent of such a member).
I AM NOT a regular or reserve member of the Army, Navy, Marine Corps, Air Force, or Coast Guard, serving on active duty under a call or order that does not specify a period of 30 days or fewer (or a dependent of such a member).
I AM a regular or reserve member of the Army, Navy, Marine Corps, Air Force, or Coast Guard, serving on active duty under a call or order that does not specify a period of 30 days or fewer.
I AM a dependent of a member of the Armed Forces on active duty as described above, because I am the member’s spouse, the members child under the age of eighteen years old, or I am an individual for whom the member provided more than one-half of my financial support for 180 days immediately preceding today’s date.
18
Getting to Know YouTell us a little bit more about you.
RENT
Please Select
RENT
OWN
OTHER
HOME OWNERSHIP
SINGLE
Please Select
SINGLE
MARRIED
DIVORCED
WIDOWED
MARITAL STATUS
GOOGLE
Please Select
REFERRAL
GOOGLE
FACEBOOK
TWITTER
NEWSPAPER
BILLBOARD
RADIO
PRINT
TV
OTHER
HOW DID YOU HEAR ABOUT US?
NAME OF REFERRAL (if applicable)
19
Would You Like to Upload Your Bank Documents Now?Enter your banking information now to finalize your approval. If you do not feel comfortable entering this information online you can bring it to the store to finalize your approval. This form is encrypted for your security.
YESNO
20
Bank Information
BANK NAME
ROUTING NUMBER (9 digits)
ACCOUNT NUMBER
YES, I HAVE DIRECT DEPOSIT
Please Select
YES, I HAVE DIRECT DEPOSIT
NO, I DO NOT HAVE DIRECT DEPOSIT
DIRECT DEPOSIT?
21
Upload DocumentsWe need your most recent bank statement or 30 days of activity (screenshots are okay), proof of income (ONLY if you DO NOT have direct deposit), and front of your picture ID.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Terms and Conditions* This field is required.
23
Privacy Notice (read carefully & sign below)* This field is required.At Discount we are committed to safeguarding the privacy of our customers. While we collect information from and about you in providing certain financial products and services, we want you to know that we strive to maintain the confidentiality of the personal information we have. We do not sell or rent to anyone the information you have provided to us. To help you understand how we protect your personal information, this notice provides an overview of our current privacy policy and practices. The Gramm-Leach Bliley Act of 1999 and recent regulations stemming from the act established new requirements for certain organizations like us regarding the provision of privacy protections for and notices to customers like you. We collect nonpublic personal information about you in order to provide, administer, and service financial products and services. This information may come from the following sources: Information we receive from you on applications and other documents. Information we receive about your transactions with us, our affiliates, or others. Information we receive from a consumer reporting agency. We restrict access to nonpublic personal information about you to employees and agents who need to know that information in connection with the financial products and services we provide to you. We do not disclose any nonpublic personal information about our customers or former customers to anyone, except as permitted by law. For example, when authorized or requested by you, we may use or disclose information provided by you to contact someone you have identified as a reference. Also, we maintain physical, electronic, and procedural safeguards that comply with federal regulations to guard your nonpublic personal information.
24
Electronic Communications* This field is required.Please check all of the methods in which we may contact you:
Voice
Text
Email
25
Consent to Receive Electronic Communications* This field is required.By reading and signing this Consent to Receive Electronic Communications Form, you consent to receive, in electronic form, notices and/or other information that we are required by law to provide you in writing. “Communications” means any notices regarding your account with Check 4 Cash as well as other information related to our services, our product, including but not limited to information that we are required by federal law to provide you in writing. Before you decide to give consent to receive information electronically, you should read and consider the following information known as the Electronic Signatures in Global and National Commerce Act (ESIGN Act). This consent will cover our communications with you during and after obtaining credit from Check 4 Cash. The words “we”, “us”, “our” refer to Check 4 Cash. The words “you” and “your” mean the customer identified in the account and application. As used in this disclosure, “account” means the account you have with Check 4 Cash. Method of Providing Communications to You in Electronic Form: If you consent, communications will be initiated electronically. All communications will be provided via 1) text or 2) email. You will have the opportunity to print this information and keep it for your records. You agree to print out or download all communications we display for you electronically and keep copies for your records. Withdrawing Your Consent: If you consent and change your mind later, you may withdraw consent at any time by contacting Check 4 Cash at 662-349-5551. By law, an invalid email address or invalid text communication will constitute an automatic withdrawal of consent. Any withdrawal of consent to receive electronic communications will be effective after we have a reasonable time to process your withdrawal. Scope of Communications to Be Provided in Electronic Form: All notices regarding our product and services, all regulatory disclosures, and all communications regarding your account with us. Communications in Writing: All communications in either electronic or paper format to you will be considered “in writing”. You should always print or download all communications. Federal Law: You acknowledge and agree that your consent to electronic communications is being provided in connection with transactions that are subject to the ESIGN Act, and that you and we both intend that the ESIGN Act apply to the fullest extent possible to validate our ability to conduct business with you by electronic means. Termination/Changes: We reserve the right, in our sole discretion, to discontinue the provision of your electronic communications, or change the conditions on which we provide you with notice of any such change as required by law.
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APPLICATION SIGNATURE* This field is required.I hereby certify that the information stated on this Application is true and correct. I authorize the verification of all information provided on this document as well as any uploaded supporting documentation. The information will be used to verify your identity.
27
Preferred ContactAfter submission what is your preferred method of contact?
Voice
Text
Email
28
References* This field is required.In case we need to verify information in order to protect your identity.
Name
Phone Number
Name
Phone Number
Name
Phone Number
29
Tags
Todo
In Progress
Done
Should be Empty: