Application

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*Amount of Loan Requested (in U.S. Dollars)

Which location is most convenient for you?

*First Name:	Middle Initial:	*Last Name:
*Address:	*City:	*State:
*Zip Code:	*Telephone Number:	*Birthdate (dd/mm/yyyy)
*Social Security Number (xxx-xx-xxxx)	*Do you: Rent Own	*How long?
*Number of People in Household:	*Number of People in Household Receiving Income:	*Make, Model, and Year of Vehicle :

*Previous Residence and Name of Landlord:

Employment Information

*Employer Name:	*Employer Address:	*Telephone Number:
*Date Employed:	*Supervisor Name:	*Supervisor Telephone Number:
*Previous Employment (Company and City)	*Day of Week or Dates Paid:	*Pay Schedule: ?
*Net Take Home Pay:	*Other Sources of Income (Net Income $, If Any)	*Work Hours and Days Off:

*Are You Currenty in a Ch. 7 or 13 Bankruptcy Proceeding?
Yes No

Bank Information

*Name of Bank:	*Name(s) in Which Checking Account is Carried:	*Bank Account Number:
Is Pay Direct Deposited: Yes No	*Date Account Opened:	*Next Check #
*Overdraft: Yes No	*Due Dates:	If any, What Company and Amount?

*Do You Have Other:

Payday Loan Signature / Installment Loan Internet Loan

References

*Reference 1: Name, Address, Telephone Number, Relationship:

*Reference 2: Name, Address, Telephone Number, Relationship:

*Reference 3: Name, Address, Telephone Number, Relationship:

Notices and Disclosures:

A R B I T R A T I O N :  Arbitration is a means for legal matters between parties to be resolved by a neutral arbitrator rather than a Court.  This Company has a policy of arbitrating all claims, demands, and disputes which cannot be resolved in a small claims tribunal, including the Scope and validity of the arbitration provision and any right you may have to participate in an alleged class action.  Whether or not you into an installment loan with us, this arbitration provision governs the resolution of disputes.  You agree that YOU ARE WAIVING YOUR RIGHT TO HAVE A TRIAL BY JURY to resolve disputes against us, our agents and/or owners.

RELEASE OF INFORMATION TO FEDERAL CASH ADVANCE: (Please read statement before signing.)  I promise that the Information I have provided on this form is correct.  I authorize complete verification of all information that I have provided as well as understand that this information may be used to verify certain past and/or current credit or payment history information from third party Source(s).  You may contact any person or company listed above, and I fully release all parties from all liability for any damage that may result.  My signature below indicates that for purposes or verification I voluntarily waive the protection of all privacy laws and affirmatively authorize Federal Cash Advance to disclose the information on this form and any additional information it may have collected about me to third parties as necessary to arrange on my behalf financial services or products that Federal Cash Advance offers from those third parties.  This application may be rejected if any information provided above is found to be false.

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By schecking this box, I acknowledge that I have received and understand my rights under the attached Privacy Policies of Federal Cash Advance of Oklahoma, LLC and Notice of my Right to Opt Out of information sharing.

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