Loan Request Form
This loan request program is intended for true financial emergencies and not for general purposes such as ordinary bills, etc. Loan requests will be assessed and approved on a case by case basis. Some factors that determine approval and loan amount includes but is not limited to: length of employment, weekly average payroll, loan capacity, outstanding company loan balance.
Employee Name
*
First Name
Middle Name
Last Name
E-mail
*
example@example.com
Store Location
*
Please note the location that you work in.
Loan Request Amount - (Max Loan Amount is $500)
*
What is the reason for the loan?
*
Have you received a loan from us in the past?
*
Yes
No
If you answered yes to the previous question, when was your last loan received?
Disclosure
If your loan request is granted, we will inform you of the loan amount and the repayment terms. We will set up automatic payroll deductions (i.e. deduct $50 from each paycheck) until the loan is repaid. You are not allowed to have more than one loan at a time. By signing below, you hereby authorize and agree to weekly payroll deductions to repay the loan until the loan is repaid in full. If the loan is not repaid in full for whatever reason (termination, etc.) the entire remaining balance may be deducted from final paycheck.
Signature
*
Date
*
-
Month
-
Day
Year
Please enter today's date.
Continue
Continue
Should be Empty: