Borrower's Name: First Middle Init. Last Date of Birth (mm/dd/yy) Social Security Number Your Mother's Maiden Name Current Driver's License or State ID # State Street (no P.O. Boxes) City State Zip Code How Long At This Address? (in years) Rent? or Own? Home Phone Work Phone Fax # (required to receive receipt or notices) E-mail Address (if available) Employment Information: Employer Your Position Address (no P.O. Boxes) Contact Person Contact Phone Note: Contact must be a supervisor or a human resources/personnel staff member. Your Hire Date (mm/dd/yy) Monthly Income $ Note: You do not have to disclose income derived from alimony, child support, or separate maintenance payments unless you want us to consider it in determining your creditworthiness. Next Payday (mm/dd/yy) Following Payday (mm/dd/yy) Is your paycheck deposited directly into your bank account? Yes No Reference 1 (Family member not living with you): Name Phone Address Reference 2: Name Phone Address Loan Amount: $100 + $15 Fee = Total Payback $115 $200 + $30 Fee = Total Payback $230 $300 + $45 Fee = Total Payback $345 - Limited to repeat customers only VIP Loan Amount*: (Before applying for a VIP Loan, contact CashOnInternet.com to see if you qualify.) $400 + $60 Fee = Total Payback $460 $500 + $75 Fee = Total Payback $575 * To be eligible for VIP Loan, you must have at least 2 satisfactory transactions in the past 12 months. Note: All borrowers must be Washington state residents and have a monthly income of at least $1,500.
If a loan is approved, your bank account will be debited on your next payday.
How did you hear about us: Newspaper Television Direct Mail Radio Internet Search Engines Word of mouth Yellow Pages Other (please specify) Comments:
By signing my name below, I authorize Lender to print a check dated on due date of Loan and drawn on bank account I have identified for amount I will owe under this loan, and to type my name on the check as evidence of my intent to authenticate it.
Name on check Street Address City, state, zip Pay to the order of: CASHONINTERNET.COM Amount *** Dollars Name of Bank Bank City/State/Zip Bank's Routing Number (1) ~ Your Account Number (2) I: I: Check # * Date ** Amount *** $ Print your full name below:
Name on check Street Address City, state, zip Pay to the order of: CASHONINTERNET.COM Amount *** Dollars Name of Bank Bank City/State/Zip
Bank's Routing Number (1) ~ Your Account Number (2) I: I:
Check # * Date ** Amount *** $ Print your full name below:
* Must be next check number in your checkbook. The paper check will need to be voided so that there are no duplicates in your account. Keep the voided check as a record of your transaction. ** Must be next payday after date of application. *** The amount on check must be equal to Total Payback Amount. (1) First set of numbers on the bottom of your check between I: and I: (2) Second set of numbers on the bottom of your check between I: and your check #
BY SIGNING MY NAME BELOW, I HEREBY: (1) Request and apply for a loan from Cashoninternet.com ("Lender"); (2) Certify that all information I have provided on this application or in connection herewith is true, correct, and complete; (3) Understand that this application is subject to approval by Lender at its offices in the State of Washington, that payments are remitted to Lender in the State of Washington, and that this transaction shall be governed by Washington law; (4) Authorize Lender, if I am approved, to credit my account identified above ("Account") via electronic transfer for the amount of the loan; (5) Understand that if I am approved and Lender makes the loan I have requested, I promise to pay to the order of Lender the principal amount of $ (fill in the amount of the loan, $100, $200, $300, $400, or $500) which along with a loan fee of $ (fill in the fee, which I understand is 15% of the principal amount of the loan) is due and payable on my next payday after the date of this application, and will be debited by Lender or its agent from my Account; (6) Authorize Lender to initiate debit entries against my Account, including printed drafts made payable to Lender or its order, for all amounts owed under this Note and to print my name on such drafts as evidence of my intent to authenticate them the same as if I had personally written and manually signed a check for the same amount. I understand that debit entries will occur on my due date for the total amount of my payment; (7) Agree that my application and this Note are not legally binding on either Lender or myself until Lender has notified me that my loan has been approved, and I understand that I may withdraw this application at any time until my loan has been approved; (8) Acknowledge that I have received the Truth in Lending Act disclosures set out below, and request and authorize that all Truth in Lending disclosures and any Equal Credit Opportunity Act notices (together, "Disclosures") which lender may provide me be provided electronically via the Internet, unless I specifically request that they be sent by fax or US mail, and unless I have asked that they be provided by fax or US mail, I further affirm that I have the capability to receive and print out a copy of such Disclosures and agree that I will print out a hard copy of all Disclosures provided by Lender electronically and retain them for my records; (9) Authorize Lender or its Assignees to charge me a NSF Fee of up to $25.00 if any check or draft signed by me or printed by Lender as authorized above is returned unpaid for any reason; (10) Authorize Lender to make credit inquiries about me to my employer, financial institutions, my current and past creditors, and to consumer reporting agencies; (11) Authorize my current and past creditors and consumer reporting agencies to furnish Lender with regular or investigative consumer reports about me; and (12) Agree that, unless otherwise provided by law, Lender shall not be liable for special, consequential, or incidental damages in connection with its action or inaction under this Agreement.
Your right to a payment plan. If this is your fourth (or greater) successive loan, and if you are not in default, you may convert your loan to a payment plan with us. "Successive loans" means loans made to you by us with no more than three business days between the repayment in full of one loan and the beginning date of the next loan. A payment plan will allow you, by paying a one time fee equal to the finance charge on your loan, to pay all that you owe in at least three payments over a period of at least sixty days.
Your right to rescind (cancel) this loan. You have the right to rescind (cancel) this loan by returning the amount of the loan in cash, or returning the check given to you by us to our office by the close of business on our next business day following the date of this loan. We may not charge you for canceling the loan and we will return to you any postdated check or electronic equivalent you have given to us.
Consumer Privacy Notice We do not disclose any non-public personal information about our customers or former customers to anyone, except as permitted by law.
Note Dated (mm/dd/yy) (Please print today's date) To Sign Print Your Full Name:
LENDER: CASHONINTERNET.COM, LLC
Annual Percentage Rate
The cost of your credit as a yearly rate
Finance Charge
The dollar amount the credit will cost you
Amount Financed
The amount of credit provided to you or on your behalf
* Estimate based on a 14-day loan Repayment Schedule: One payment of $ due next payday after date of application. If your loan is paid before its due date there will be no rebate of finance charge. See the Note for additional information about nonpayment and default. Itemization of the Amount Financed: The Amount Financed of $ consists of $ given to you directly.