Loan Application Form

Save Time, Apply Online for Your Payday Loan

Must live in the State of Kentucky.
Contact Information
Title:
Birth Date*

MonthDayYear
E-mail*
Name*

First NameLast Name
Phone*

Area CodePhone Number
Cell Phone*

Area CodePhone Number
SSN#*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How long have you lived in your given address?*

0-1 Year1-2 Years3-4 Years5+ Years
Employment Information
Present Employer*
Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Employer Phone*

Area CodePhone Number
Supervisor's Name*

First NameLast Name
Years at this employer*

0-1 Year1-2 Years3-4 Years5+ Years
Pay Day Schedule*
Day of Week Paid*
Take Home Pay*
Hours Worked? (9-5)*
How Much Did You Want to Borrow?*
Spouse's Name

First NameLast Name
Spouse's SSN#
Spouse's Employer
Spouse's Phone

Area CodePhone Number
Relative Name*

First NameLast Name
How related?*
Relative's Phone*

Area CodePhone Number
Relative #2 Name*

First NameLast Name
How related?*
Relative's Phone*

Area CodePhone Number
Relative #3 Name*

First NameLast Name
How related?*
Relative's Phone*

Area CodePhone Number
Bank Name*
Checking Acct Number*
How Long Has this Account Been Open?*
How would you like to be notified if this loan is approved?*
Are you a regular or reserve member of the military, or Are you a dependent of a member of the military?To ensure important federal protections are provided to active members of the military, and their dependents please answer the following questions

YesNo
Is the following statement true? After completing this transaction, I will not have more than 2 payday loans outstanding with Advance-U-Cash or any other company, and the total amount that I owe will not exceed the Kentucky state payday loan limit of $500.

YesNo
I certify that the information supplied by me on this form is true and correct. I authorize verification of the truthfulness of all information herein, including contact with any person or firms listed above, and fully release all parties from all liability for any damage that may result. Any false statement made above shall be sufficient basis for rejection. I have read and understand the above statement.*

YES
Type in Legal Name
Signature

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Should be Empty:

Save Time, Apply Online for Your Payday Loan

Contact Information

Employment Information