American Cash-2-Go - Application Form

Personal Information
Last Name
 First
 Middle
 Sex
Social Security No.
 Birth Date
 Driver's License or State ID No.
 State
 Next Payday
Home Address
 Apt. #
 City
 State
 Zip
Home Phone #
 How long at current address?
 Phone in whose name?
Yourself Friend Relative
Previous Address (if less than 1 year at current address)
 Message Phone or Other Phone #
 Utilities in whose name?
Landlord/Mortgage Co. / Address
 Phone #
 Do You:
Own Rent Other

Employment Information
Current Employer
 Address
 Full-time
Part-time
Work Phone #
 Extention
 Title
 How long at current job?
Paid:
Once a week Twice a month
Once a month Other 		Day of Week Paid
 Take Home Salary
 Supervisor Name and Phone # w/ Extention

Banking / Check Information
Bank Name: Checking Account
 Checking Account #
 Checking Account Open How Long?
 Next check number
Bank Name: Savings Account
 Savings Account #
 Savings Account Open How Long?

Social Security/SSI Recipient 
If yes, is your check direct deposited?

Yes No
Yes No		 Pension Check Recipient?
Yes No
If yes, is check direct deposited? Yes No		 If you have direct depost, to what bank?
Acct. #

Vehicle Information
Car Information: Make
 Model
 Year
 Color
 License Plate #

Spouse Information
Last Name
 First
 Middle
 Birth Date
 Driver's Licence #
Employer
 Address
 Work Phone #
 Title
 Full-time Part-time
 How Long?

Personal References
Name
1.		 Address
 City, State, Zip
 Phone #
 Relationship
2.

Read Statement Before Signing:
I certify the information supplied by me on this form is true and correct.  I authorize verification of the truthfulness of all information contained herein, including contact with any person or firm listed above, and fully release all parties from 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.

 

Signature_______________________________________ Date________________