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| Personal Information |
| Telephone numbers must be 10 digits. Do not include spaces or dashes. |
| First Name |
Last Name |
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| Gender |
Home Address |
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Male
Female
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| City |
State Zip |
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| Do you |
How long at this address? |
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Rent
Own House
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Years
Months
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| Email Address |
Telephone |
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| Cell Number (optional) |
Alternate Number |
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| Birth Date |
SSN (no spaces or dashes) |
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| Driver License # |
License State |
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| Are you a US Citizen? |
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Yes
No
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| ........................................................................................................................................................................... |
| Employment Information |
| Are you currently employed, and have been for three months? |
How many hours do you work per shift? (per day) |
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Yes
No
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| Company Name |
Job Title |
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| Work Number |
Date Hired |
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| Supervisor's Name |
Main source of your income |
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| How often do you receive a paycheck? (must match the paycheck dates below) |
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Weekly
BiWeekly
Monthly
TwiceMonthly
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| How do you receive your pay? |
Monthly Pay |
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| Date of your next paycheck |
Date of paycheck after next |
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| Are you, your spouse or someone who claims you as a dependent currently in the Military? |
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Yes
No
Don't know
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| ........................................................................................................................................................................... |
| Bank Information |
| Do you have an active checking account? |
Bank name |
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Yes
No
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| Bank routing number |
Bank account number |
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| How long have you had your account at this bank? |
How many outstanding loans do you have? |
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Years
Months
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| Requested loan amount |
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| References |
| First reference's full name |
Second reference's full name |
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| First reference's phone number |
Second reference's phone number |
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| First reference's relationship |
Second reference's relationship |
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| *EliteCashWire.com is an advertising agency only, not a financial institution or lender. EliteCashWire.com will place you with one of several loan providers depending on the information you submit on this website. Not all lenders can provide up to $1000. Cash transfer time may vary between lenders. Please be sure to review the terms and conditions of each service prior to doing business with them as Cash Advance charges vary by lender. This service does not constitute an offer or solicitation for short term loans in every state and may or may not be available in your particular state. The states in which this service is available may change from time to time without notice. |
