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Married applicants may apply for separate credit.

Last Name

First

MI

Birth Date

Social Security Number

Street Address

City

State

Zip

How long at Address?

________ yrs

________

mos.

Mortgage

Rent

Email Address

Home Phone Number

Cell Phone Number

$

(

)

(

)

Present Employer

Street Address

City

State

Zip

Job Title / Position

Monthly Take-home Income

*$

Pay Days:

Weekly

Every 2 Weeks

Twice a Month

Monthly

Hire Date

Supervisor’s Name

Dates or Days of Week Paid:

Direct Deposit? Yes

No

Company Main Number

(

)

Your Direct Work Number

(

)

*Income from alimony, child support or separate maintenance payments need not be revealed if you do not want to have it considered as part of your application.

Spouse’s Name

Cell Phone Number

Work Phone Number

(

)

(

)

Bank Name

Checking Account No.

Bank Phone Number

(

)

1. Relative Name

Relationship

City, State

2. Reference Name (not living with you)

Relationship

City, State

Phone Number

(

)

Phone Number

(

)

How did you hear about us? (Please circle one)

Yellow Pages

Friend/Family

Drive By/Sign

TV

Radio

Newspaper

Direct Mail

Internet

Other

__________________

Yes

No

Yes

No

Yes

No

1. Have you ever filed or are you contemplating filing for bankruptcy, or do you have a bankruptcy

2.

proceeding in progress? Do you have any other payday advances outstanding at this time? With whom? If yes, when was the bankruptcy discharged? _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

3. Are you on active military duty or a spouse/dependant of someone who is?

, you certify that the above and accompanying information is accurate and complete. You authorize Payday Loan, LLC to obtain credit reports on you and to verify the information you provided from whatever sources it chooses, which may include calling your employer and references, and to release information about its credit experiences with you to credit bureaus and others. Any false statements made above shall be sufficient basis for rejection. You acknowledge that this application and any supporting documents provided with it are Payday Loan, LLC’s property and that photocopies, telecopies or electronic copies or images of documents you sign are as valid and enforceable as original written and signed versions of the same material. As required by law, you are hereby notified that a negative credit report reflecting on your credit record may be submitted to a credit reporting agency if you fail to fulfill the terms of your credit obligations.

Applicant’s Signature:

_______________________________________

Date:

_____________

For Office Use Only

Store No.

Representative

Amt. Approved

PDL 4012 (10/09)

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