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This application is 100% secure and confidential.
Please fill out the entire application and click the Submit button below.

Tell Us About Yourself:

First Name / MI / Last Name:

  

Email:

Confirm Your Email:

Alternate Email:

Street Address:

City / State / Zip:

   

Length at Address:

year(s) &  month(s)

Home Phone:

Cell Phone / Pager:

Home Fax:

Tell Us About Your Job:

Employer:

Position:

Employer's Address:

City / State / Zip:

   

Work Phone:

 Ext:

Work Fax:

Number to Verify Employment:

Length of Employment:

years(s) &  month(s)

Average Paycheck Amount:

How often do you get paid?

Day of week usually paid?

Please enter your
next two paydates:

   
   

Is your paycheck directly deposited?

NOTE: For an expedited approval please fax your most recent bank statements.
Our fax number is 1-888-263-0700.

Tell Us About Your Bank:

Bank Name:

Account Number:

Routing Number:

Type of Account:

Bank Phone:

How long have you had this account?

year(s) &  month(s)

How many NSF have you had in past 6 months?

Provide Three References:
Two Relatives and one friend not living with you.

 

Name:

Relationship:

Home Phone:

1.

2.

3.

Personal Information for Account Security:

Social Security Number:

Birthday:

   

Driver's License Number:

State License Issued:

Mother's Maiden Name:

Have you used a payday loan service before?

Do you have any payday loans outstanding?    If Yes, how many?

Have you bounced any checks in the last 30 days?

NOTE: PLEASE BE TRUTHFUL ABOUT THE NUMBER OF PAYDAY LOANS OUTSTANDING AND ANY BOUNCED CHECKS WITHIN 30 DAYS. WE VERIFY THE INFORMATION WITH A NATIONAL DATABASE.

How did you learn about us?

Referred by Friend

 

name of friend:

Search Engine

 

which one:

Other

 

specify:

You have finished the application! Make sure that all fields are correct and filled in. You may be denied for an incomplete or inaccurate application.

Please proceed to the Payday Advance Request Below.

Easy Cash Now Advance Request
Please fill out the check below. When we receive it, we will process your cash advance.

Bank Name: 

Check Number: 

Pay to the Order Of: Access EZ Cash, Inc.

Amount $ 

Next Payday:     


(Type entire line of digits on bottom of your check in the box above.)


(Type your signature in the box above.)

THERE WILL BE A $10 APPLICATION FEE DEDUCTED FROM YOUR WITHDRAWAL

 

CASH ADVANCE INTERACTIVE CALCULATOR

Use the calculator below to find out the amount of your Cash Advance

          Step 1) Type in the amount of the check:

$

          Step 2) Click Calculate:

          Step 3) The amount of your payday advance:

$

Access EZ Cash, Inc. is authorized to withdraw the amount selected on the check from my checking account on the DATE indicated above. I understand and agree to pay $15 if the check is returned for ANY reason. Furthermore, I authorize Access EZ Cash, Inc. to initiate either the whole amount or portions of the amount until fully paid. These partial payments may be originated at any time after the original due date. This activity shall remain in full force and effect until my financial institution and Access EZ Cash, Inc. have received, in writing, a notice of its termination of at least 30-days prior to the date of termination. If I wish to pay this item before the due date, I acknowledge that such payments must be made at least two (2) days before the due date, not counting weekends or bank holidays. I also authorize Access EZ Cash, Inc. to run a credit report through TeleTrack to approve my account.

IF YOU HAVE OUTSTANDING PAYDAY LOANS ELSEWHERE, WE WILL NOT PROCESS YOUR LOAN.

By typing your name in the following box, you acknowledge that you have read the Truth in Lending Agreement.
 

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© 2004-2008 Access EZ Cash, Inc. All rights reserved.
05-11-2008