New Customer Application

New Customer Line of Credit Application

Approval Requirements:

Full time employment or have other documented monthly income.
Minimum net income of $1500 (after taxes and deductions) salary per month.
Have an active checking or savings account in good standing and open for a minimum of 2 months.
Be at least 18 years of age.
Your application is subject to underwriter approval.

1Your Information

2Expenses

3Income

4Final Information

Name*
First Last
Email*
Phone 1*
Phone 2
Fax
Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Driver's License #*
State Issued*
Social Security Number*
Referred by

Do You Own or Rent?*
- Own
- Rent
Monthly Housing Payment*
How Many Other Loans Do You Currently Have?*
How Much Do You Owe In Total?*

Employer Name*
Employer Phone*
Employer Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Monthly Net Income*
How Often Are You Paid?*
What Day of The Week?*
First Day of the Month*
Second Day of the Month*
What Day of the Month?*

Requested Loan Amount*
Please enter a number from 300 to 1000.
Choose Your Due Date (within 15 days from now)*
Month
Day
Year
Name of Bank*
Account Number*
Routing Number*
Type of Account*
Bank Phone Number
Bank Card Information

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Name on Card
Your card information is for validation purposes only. No fees will be charged without approval.
Consent*
I have read and understood, and agree to ALL terms, disclosures, and conditions.*
I understand I will be contacted by telephone at the numbers provided on this application to confirm my approved Line of Credit amount and will receive by email my Line of Credit Loan Agreement for my review and electronic signature prior to funding my requested line of credit draw.

Legal/Disclosure Acknowledgement: If you acknowledge that you have read and agree to the terms listed in the National Cash Lenders Initial Disclosure Notice, verify by clicking the yes button below to continue. You may review these documents on our Disclosures page.

I also agree that I have reviewed National Cash Lenders Federal E-SIGN Act Disclosure and Consent and acknowledge and consent that all 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 National Cash Lenders Initial Disclosure and is valid and enforceable in accordance with the "Electronic Signatures in Global and National Commerce Act". Click here to review the National Cash Lender's Federal E-SIGN Act Disclosure and Consent.

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. I agree that upon submission of my electronic signature, I am not presently involved in, nor contemplating bankruptcy proceedings now or in the future.
Electronic Signature*
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