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Terms of Use
for Cash 211 Payday Loans.
Click here if you agree:
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I Agree
Personal Information
First Name:
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Last Name
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Middle
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Street Address:
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Appartment #:
City:
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State:
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Zip code:
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E-mail:
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Home Phone:
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Work Phone:
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Cell Phone:
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Drivers License Number:
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Drivers License State:
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Date of Birth:
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Year
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SSN
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Please provide information on one person that lives with you. (i.e., partner, roomate, spouse, parent, etc)
Name of Person living with you:
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Living Situation
Do you own or Rent your home?
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Own
Rent
Years/Months in home:
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Mortgage/Rent Amount (in dollars - $):
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Military Service
Are you a member of the Military?
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Yes
No
Is your Spouse a member of the military?
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Yes
No
Additional Information
Are you currently in or planning to file Bankruptcy?
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Yes
No
Previous Address: (City, State)
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Employment Information
Primary Employer: (Name and Address)
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Work Status:
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Full Time
Part Time
Social Security
Public Assistance
Part Time
Disability
Supervisor Name:
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Supervisor Phone:
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Monthly Income:
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How long have you received this monthly income:
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Pay Schedule:
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Weekly
Every Two Weeks
Monthly
Bi-Monthly
Do you receive Direct Deposit?
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Yes
No
Next Pay Date:
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Month
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Day
Year
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Banking Information:
Bank Name:
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Checking Account Number:
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Routing Number:
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Reference 1 of 3:
"Local References Preferred."
Type of Reference
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Friend
Coworker
Name:
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Address (Appt #):
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City:
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State:
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Home Phone:
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Zip Code:
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Cell Phone:
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Work Phone:
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Reference 2 of 3:
Type of Reference:
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Parents
Family Member
Name:
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Street Address (Appt #):
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City:
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State:
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Zip Code:
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Home Phone:
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Cell Phone:
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Work Phone:
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Reference 3 of 3:
Type of Reference:
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Landlord
Mortgage Company
Name:
*
Address (Appt #):
*
City:
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State:
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Zip Code:
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Home Phone:
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Cell Phone:
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Work Phone:
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Picking Up Your Loan
If your loan is approved, which location would you like to pick up your funds? (Please see our store locator for directions)
Locations:
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955 West Garden of the Gods Road
2918 Wood Avenue
Signature
By inputting your initials below and submitting this Application, I am verifying that all of the information in this Application is accurate and correct, including the personal references and contact information. I have acknowledge and warrant that the checking account listed above is legitimate, open, active account. I represent that I am not a debtor under any preceding in bankruptcy and have no intention to file a petition for relief under any chapter of the U.S Bankruptcy Code.I also agree that I have read and understand all the above important disclosures and information on cash211.com, including the Arbitration Provision.
Initial For Signature
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