PayDay Loan Application - RepubliCash

Name (Last) Street Address

(First) City

State

Previous Address (If less than 3 years at above)

Spouse's Name (Last)

(First)

(Middle) Zip

(Middle)

PayDay Loan Application

Mr. Ms. Social Security Number Mrs.

Home Phone

Own

Rent

(Area Code) Driver's License #

Date of Birth

(State) Spouse's Work Phone # Spouse's Employer

How long?

Do you have a checking account? Yes No

Bank

Employer (or source of income)

Work Phone

Work Address:

(Area Code)

Take home $

Checking Acct # Pay Period

Time at job? Once per week

(yr / mos)

Once per month Twice per month

Wage garnishments? Yes No

Next Payday?

Job title

Full Time

Supervisor's Name

Phone #

Ever file bankruptcy? Yes No

Previous Employer

Part Time

Discharge Date

Hours per week?

In bankruptcy now? Yes No

(If under 3 yrs at current)

Make of Car___________________Model________________Year_______Color_______________License plate#______________State______

1. Name

Street

City, State, Zip

Phone

Relationship

2. Name

Street

City, State, Zip

Phone

Relationship

3. Name

Street

City, State, Zip

Phone

Relationship

E-mail:

Consent For Credit Information By signing "Consent for Credit Information", I/We understand that I/We give RepubliCash the right to use this document for the purpose of obtaining any and all info which may be pertinent to securing a pay day advance loan, (hereinafter "loan") I/we understand that information may be requested from the following sources: past, present employers, financial institutions, or any source which relates to credit matters, debt obligations, and available assets which could affect my/our loan. The interest obtained by the lender, its agents or assigns is to be used in the processing of my application for a loan. This information may also be used in conjunction with quality control review of the file after the loan has closed.

This form may be reproduced or photocopied and when used shall be as effective as the original signed document currently held by the lender.

I HEREBY ACKNOWLEDGE RECEIPT OF THESE NOTICES

initial: _________

Equal Credit Opportunity Notice The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants in the basis of race, color, religion, national origin, sex, status or age (provided the applicant has the capacity to enter into a binding contract); because all or part of the applicant's income has been derived from any public assistance program; or because the applicant has , in good faith, exercised any right under the consumer credit protection act. The federal Agency that administers compliance with the law concerning this creditor is:

The Federal Trade Commission Washington, DC 20508

I HEREBY ACKNOWLEDGE RECEIPT OF THESE NOTICES

initial: _________

Consumer Protection Bond

A consumer protection bond is on the file with the State of Maine. If you have a claim against our company which cannot be resolved through

informal means, you may take action to recover your loss from that bond by filling a written complaint with the Director, Office of Consumer Credit

Regulation, 35 State House Station, Augusta, ME 04333-0035

I ACKNOWLEDGE READING AND RECEIVING A COPY OF THIS DISCLOSURE TO CONSUMER

Initial:_________

Tele-Track

I understand that RepubliCash does not perform a lengthy credit check on applicants but does perform a search in the Tele-Track database.

Tele-Track is a national database of consumers who have a record of certain transactions in certain industries including, but not limited

to, deferred deposit, check cashing, rent-to-own, cable television, accounts, consumer finance companies, and retail furniture stores.

I agree to and authorize such a search.

Please Read Before Signing

I certify that the information supplied by me is true and correct. I authorize verification of the truthfulness of all information contained herein,

including contact with a firm listed above, and fully release all parties from any and all liability for any damage that may result. Any false

statement made by me shall be sufficient basis for RepubliCash. I acknowledge that this application and any supporting documentation provided

with it is the property of RepubliCash LLC.

Applicant's Signature _________________________________________________________Date_____________________________________

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