Loan Application

Complete the application below to apply for a loan. Some fields are required as indicated.

Personal Information

Last Name (required)

First Name (required)

Middle Name

Courtesy Title (Mr. / Ms. / Mrs.)

Your Email (required)

Home Phone (required)

Street Address (required)

City (required)

State (required)

ZIP Code (required)

Own or Rent?

How long?

Previous Address (If < 3 years at above)

Date of Birth (required)

Social Security Number (required)

Driver's License # (required)

Spouse's Name (Last) (First) (Middle)

Spouse's Work Phone #

Spouse's Employer

Financial Information

Do you have a bank account? (Yes/No)

Name of Bank

Savings or Checking?

SavingsChecking

Routing #

Are your wages being garnished? (Yes/No)

Employment Information

Employer (or income source):

Job Title:

Work Address:

Work Phone:

Supervisor's Name:

Supervisor's Phone:

Part Time or Full Time?

Time at job?

Hours per week?

Take-home Pay:

Pay Period (Weekly/Monthly/Bimonthly):

Next Payday?

Previous Employer:

Discharge Date (yr / mos):

Bankruptcy Information

Ever file bankruptcy?

In bankruptcy now?

Vehicle Information

Make of Car:

Model of Car:

Year:

Color:

Plate #:

State:

References

Name
(required)

Street
(required)

City, State, ZIP (required)

Phone (required)

Relationship (required)

Name
(required)

Street
(required)

City, State, ZIP (required)

Phone (required)

Relationship (required)

Name
(required)

Street
(required)

City, State, ZIP (required)

Phone (required)

Relationship (required)

Required Documents - Upload Center

1. Verify your employment/source of income.
Please upload and image or your most recent paycheck stub or up-to-date benefit letter. (Employed for at least 3 months minimum)

2. Confirm your home address.
Please upload an image of a utility bill as proof of physical address. (Also accepted is a rental lease agreement or car registration)

3. We verify that you have an active and good standing checking account.
Please bring your most recent 60 days of bank statements (last 2 months) for your checking account and your checkbook. (Account open 3 months minimum)

4. We also accept automatic withdrawal information if you do not have checks.
Please have your financial institution print your ACH account and routing number on their letterhead. This information can also often be found on your online banking account. Please upload an image. (Handwritten account numbers are not accepted)

Please bring your valid government issued ID.

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 (required)

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 (required)

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 (required)

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 (required)

Date (required)

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