Cash In A Wink

Loan Application

Step 1 - Customer Information

First Name:
Middle Name:
Last Name:
Email Address:
Confirm Email Address:
Address 1:
Address 2:
City:
State:
Zipcode:
Country:
Date of birth:	- -
Phone Number:	- -
SSN:	- -
Id Type:
Id Number:
Id State:
Id Country:
Requested Loan Amount:

How long at this address?	Years: Months:
How did you hear about us?
Are you or your spouse a member of the military?	YesNo
Can you be claimed as a dependent by an active military member?	YesNo

Step 2 - Employer Information

Income type:
Job Title:
Work Number:	- - Ext:
Supervisor Name:
Supervisor Number:	- - Ext:
Employer Name:
Address 1:
Address 2:
City:
State:
Zipcode:
Country:

Step 3 - Payroll Information

Type of employment:

Full timePart time

Have you recently filed or are planning to file for bankruptcy?

YesNo

How do you receive your paycheck?

Direct depositPaper check

Paycheck Amount:

$.00

How are you paid when a pay day falls on a non-business day?	BeforeAfter
How often do you receive a paycheck?	WeeklySemi-Monthly Bi-WeeklyMonthly
(Please enter date in this order and format: mm/dd/yyyy) If your last or next pay date falls on a national holiday or weekend please use that day.
Last Pay Date:
Next Pay Date:

NOTE: These MUST be accurate to calculate your loan. These pay dates are for verification of your pay cycle only and do indicate a payment cycle of any kind

Step 4 - Bank Information

YOU MUST BE LISTED AS AN ACCOUNT HOLDER AND SIGNER ON THIS ACCOUNT IN ORDER TO PREVENT FRAUD. THIS INFORMATION WILL BE VERIFIED WITH YOUR BANK.

Bank Name:
ABA Number:
Account Number:
Account Type:	CheckingSaving

How long has this account been open?

Years: Months:

Step 5- Reference Information

Please supply a contact, this person must be a relative NOT living with you.
First Name:
Last Name:
Phone Number:	- -
Relationship: