Application Form | Easy Cash America

Customer Information

First Name*

Last Name*

Sufix

SSN*

Email Address*

Date of Birth*

Valid Driver's License or State ID Number*

State Issued*

Home Phone

Cell Phone*

Best Time to Call*

Section Break

Address*

City*

State*

Zip Code*

Time at Address*

Residence*

Own Residence

Rent Residence

Bank Information Find Your Routing Number

Routing Number*

Account Number*

Bank Name*

Bank Address*

Bank City*

State*

Zip Code*

Bank Phone Number*

Account Type*

Debit/Credit Card Information

Name on Card*

Card Number**

Billing Address*

Expiration Date*

Bank City*

State*

Zip Code*

Income & Employment Information

Income from alimony, child support or separate maintenance payments need not be disclosed if you don't wish us to consider this as a source of repayment.

Monthly Income*

Income Type*

Payroll Type*

Pay Frequency*

Pay Day*

Next Pay Day*

Exact Pay Day*

Relative Pay Day*

Exact Pay Day*

Relative Pay Day*

If Payday On Bank Holiday

Do Nothing

Move to Previous Business Day

Move to Next Business Day

Employer Information

Employer*

Occupation

Date of Hire*

Work Phone Number*

Employer Address

Employer City

State

Zip Code

Shift*

Military

Federal law provides important protections to active duty members of the Armed Forces and their dependents. To ensure that these protections are provided to eligible applicants, we require you to sign one of the following statements as applicable: *

Military*

Yes

I AM a regular or reserve member of the Army, Navy, Marine Corps, Air Force, or Coast Guard, serving on active duty under a call or order that does not specify a period of 30 days or fewer.

- or -

I AM a dependent of a member of the Armed Forces on active duty as described above, because I am the member's spouse, the member's child under the age of eighteen years old, or I am an individual for whom the member provided more than one-half of my financial support for 180 days immediately preceding today's date.

or

No

I AM NOT a regular or reserve member of the Army, Navy, Marine Corps, Air Force, or Coast Guard, serving on active duty under a call or order that does not specify a period of 30 days or fewer (or a dependent of such a member).

Text Message Communication

Communication*

Yes, please send me account-related messages such as payment reminders to the cell phone number provided.

Yes, please send me promotional messages to the cell phone number provided. Opting in for promotional messages is not a requirement to receive the services you’ve requested from Easy Cash America. Promotional messages will be sent to approved carriers only.

By checking the above, you are opting in to receive SMS text messages from Easy Cash America. Message and data rates may apply. Message frequency will vary. To opt-out at any time, reply STOP to any message we send, or HELP for more information. Privacy Policy and Terms and Conditions

Landlord Information

Landlord Name*

Landlord Phone Number*

Rent/Mortgage Mount*

Rent/Mortgage Due Date*

References

First Name*

Last Name*

Relation*

Phone Number*

Address

City

State

Zip Code

Additional Information

How did you hear about us?*

Details

Promo Code

Parents Name

Parents Phone Number

Loan Information

Loan Amount*