| Select
Your Advance Amount Requested:
|
| I
would like to be enrolled in the Instant Cash Card Program
If Yes, please confirm your mailing
address |
| City |
|
State |
Zip
|
| If
you already have an Instant Cash Card and would like this
Advance applied to it, check here.
|
| Due
Date:
(mm/dd/yy) | Due
Date is your next pay date, up to a maximum of 15 days |
| Do
you currently have an advance with another provider?
|
Enter
ANY Information Changes and/or comments in the box below:
(such as changes in employment,
address, phone numbers, bank info, promotional codes)
|
| I
authorize National Cash Lenders to deposit the amount
I have requested, AND HAVE BEEN PREVIOUSLY APPROVED
FOR (shown as "Advance Amount Requested")
into my account and to ACH/EFT debit my account for
the advance amount plus fee on the date specified above.
I
agree to maintain an adequate balance and keep my account(s)
open to allow all ACH/EFT and/or bank drafts to National
Cash Lenders to occur in a timely manner for the scheduled
due date. I further agree and confirm that by submitting
completed/ signed National Cash Lenders.com internet
request forms as a matter of convenience, hereby constitutes
the same legal and binding document as providing National
Cash Lenders with my personal post dated check, in the
amount of the cash advance plus associated fees.
If the payment is returned for ANY reason, I agree that
I will also pay a $30.00 return fee. I agree that upon
submission of my electronic signature, I am not presently
involved in, nor contemplating bankruptcy proceedings
now or in the future.
I
understand, acknowledge, and fully agree this transaction
is NOT an installment loan that I can make payments
on, but is due in full on the due date above. Furthermore,
it is pursuant to the Master Cash Advance Agreement,
which has been previously executed and is on file with
National Cash Lenders.
*National
Cash Lenders will provide one replacement cash card
at no charge. Any replacement cards will be provided
at a cost of $30.00 per card.
National
Cash Lenders, LLC. does not service any U.S. Armed Forces
members or it's dependants. By signing I
certify that I nor any of my dependants are in any of
the U.S. Armed Forces.
|
| I
understand and agree.
(Please
type your signature) |
|
For your records, please print
a copy of your completed application before submitting.
|
| Notice:
It takes 3 to 5 business days to receive confirmation
from your financial institution that your previous advance
payment cleared your account.
If
your previous advance due date was within the past 3
to 5 days (and you have online banking) for your convenience,
locate your bank's online services using our BANK
LISTINGS PAGE. This online bank resource page
has listings for all online banks. Simply fax a printed
bank statement showing confirmation of your previous
advance payment to toll free 1-877-369-0506, OR e-mail
the confirmation to customerservice@nationalcashlenders.com
and put your name in the subject line. We will then
be able to process your new cash advance request the
same day, without having to wait for report of payment. |