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EZ CASH PAYDAY LOAN APPLICATION


  1. 1Personal Information
  2. 2Income
  3. 3Account Information
Amount requested: $
First Name:
Last Name:
Cell Phone:
Other Phone:
E-Mail:
My preferred communication:
Street Address:
City:
State:
ZIP:
Driver license ID No:
Driver license Issued State:
Social Security No:
Date Of Birth:  (mm-dd-yyyy)
Personal reference First Name:
Personal reference Last Name:
Relationship:
Reference Phone:
Are you or your spouse an active military member?:  
Can you be claimed as a dependent by an active military member?:
How did you hear about us?
Primary Source Of Income:
Work Phone:  EXT
Job Title:
Supervisor:
Net pay per paycheck:
Frequency of pay:
Direct deposit:
Name of Employer:
Last Pay Date:
Next Pay Date:
 
Financial Institution Name:
Financial Institution City:
ABA / Routing Number:
Account Number:
Longevity of account:
Choose Check Center store to pick up cash:
 

By filling my full name in the Signature box below and submitting this application, I hereby authorize Check Agencies of California, Inc. (CAC), to verify all information I have given in connection with this payday loan or any subsequent payday loan. I further authorize CAC to contact my employer, access my account information, and contact references for purposes of verification or collection of returned items. This authorization shall remain effective until a written revocation is received by CAC.

 
Signature:        Date: