| First Name |
|
Middle
Name |
|
| Last Name |
|
Birth Date
(mm/dd/yy) |
|
| Home Phone |
|
Cell Phone |
|
| Mother's Maiden Name |
|
Address (no
PO Boxes) |
|
| City |
|
State |
Zip
|
| Housing |
Own
Rent Apartment
Monthly Housing Payment $
|
| Driver's License#
|
|
State Issued |
|
| Fax |
|
Number of
Other Advance(s) & Amount(s) Owed |
|
| Email |
|
Work Email
(if different) |
|
| Employer Name |
|
Employer Address |
|
| City |
|
State |
Zip
|
| Employer Main Phone |
|
Work phone |
Ext.
|
 |
| I would like
to recieve a FREE Instant Cash Card
If Yes, please confirm your mailing
address |
|
| Are you paid
by direct deposit?
|
| Monthly
net(take home) income
|
| What
are your scheduled pay dates?
Note: We can no longer accept monthly paid customers |
| If weekly
or bi-weekly, what day?
|
| Your
next two pay dates
And
|
| Please make
sure the above dates are selected correctly to reflect
your actual paydates so we may complete your application
process without delay. |
|
Bank
Routing/Account Numbers are located at the bottom of your
personal check.
Click here
for a sample check. |
| Name of Bank |
|
Bank Phone |
|
| Transit Routing Number |
|
Bank Account
Number |
|
| Account Type |
|
| Request Loan Amount |
|
| Due Date |
Your next pay date (up to a maximum 15 days) |
|
| UPON APPROVAL
, I authorize National Cash Lenders 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 or $25 per $100 advanced to me, on the date
specified above. If within 24 hours of the loan being
originated, the customer at his or her option may rescind
his/her loan. The loaned funds will be electronically
withdrawn from the customers banking account, and no
fees will be charged. You must notify our office
in writing prior to the 24 hours expiring at customerservice@nationalcashlenders.com
and we will terminate the loan. 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 National Cash Lenders to occur in a timely manner
for the scheduled due date.
I further agree and confirm that by submitting completed/
signed nationalcashlenders.com internet request forms
as a matter of convenience, hereby constitutes the same
legal and binding document as providing National Cash
Lenders 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 $30.00 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 National Cash Lenders Internet Master
Cash Advance agreement (which will be on file with National
Cash Lenders) and is NOT an installment loan that I
can make payments on, but is due in full on my next
nearest pay date.
National Cash Lenders, LLC. does not service any U.S.
Armed Forces members or it's dependants.
By signing I certify that I nor any of me dependants
are in any of the U.S. Armed Forces. |
|
|
I have read, understand, and agree to ALL terms, disclosures,
and conditions of the National Cash Lenders Internet Master
Cash Advance Agreement. |
|
(MUST Select One BEFORE CONTINUE) |
| |
| By electronically
signing this form I acknowledge that all information provided
by me in this application is true and correct and authorize
National Cash Lenders LLC, its successors, and assigns,
to verify any and all information contained herein. Furthermore,
I authorize National Cash Lenders 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 |
|
|
Type your Social Security Number |
|
| Please
confirm your Social Security Number |
|
| Referred
by: (Needed to receive their referral bonus) |
|
Click
here for more information |
Any
additional comments, type here:
|
| |
| After
you submit this application, you will be forwarded to
the Agreement Signature Page. Please PRINT, SIGN and
FAX with the required verification items. Once these
items are received, only then will your approval process
begin. The approval process takes approximately 30 minutes.
You
can also attach and e-mail the required documents to
newapplication@nationalcashlenders.com |
|
| For your
records, please print
a copy of your completed application before submitting.
|
|
| Click
to SUBMIT your information for processing.
|
| |
| 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. |
| 2nd
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. This transaction is deemed to have taken
place in Delaware and all regulations governing this
transaction are in accordance with Delaware law.
If you are in need of credit counseling help, please
refer to National Foundation for Credit Counseling located
here.
|