Applicant Information
Which Location is most convenient for you?
Chicago (Loop/Downtown): 570 W. Roosevelt Rd.
Chicago (North): 1150 W. Belmont
Chicago (Northwest): 3555 W. Irving Park Rd.
Chicago (Northwest): 4016 N. Cicero
Chicago (West): 6 N. Austin
Chicago (South): 10302 S. Halsted
Calumet City: 667 River Oaks Dr.
Dolton: 1107 E. Sibley
Belleville: 1630 carlyle Ave.
Centralia: 435 S. Elm St., Unit 1
Champaign: 821 Bloomington Rd.
Decatur: 2891 North Water St.
Du Quoin: 799 S. Washington
Effingham: 1214 S. Banker St.
Granite City: 3717 Nameoki Rd.
Litchfield: 14-1 Litchfield Plaza Shopping Mall
Mattoon: 221 Lake Land Blvd.
Mt. Vernon: 3216 Broadway
Olney: 1214 Main St.
Sparta: 1701 N. Market
Email Address:
Last Name:
First Name:
M.I.:
Social Security number:
Date of Birth:
Current Street Address:
Apt.:
City:
State:
Zip:
Own
Rent
Other How Long?
Home Phone:
Cell Phone:
Landlord's Name:
Landlord's Phone:
Employment Information
Current Employer:
Position/Dept.:
Work Phone:
Address:
City:
State:
Zip:
Supervisor/Manager:
Supervisor's Phone:
How Long Employed?
Pay Frequency (check one):
Weekly:
Bi-Weekly
Twice/Month
Monthly
Day(s) of Week/Month Paid:
Monday
Tuesday
Wednesday
Thursday
Friday
1st
15th
Last Day
Other
Next Pay Date:
Net Pay/Period (after taxes & withholdings):
Have Direct Deposit?
Yes
No Any Wage Garnishments?
Yes
No
Other Income
Other Income:
Source of Other Income:
Ever File for Bankruptcy?
No
Yes... If Yes, Discharge Date of Previous BK filing:
Currently in Bankruptcy?
No
Yes
Banking Information
Have a Checking Account?
Yes
No
Bank Name:
Account Number:
How Long Open?
Have a Savings Account?
Yes
No
Bank Name:
Account Number:
How Long Open?
References
Nearest Relative:
Relationship:
Phone:
Other Relative:
Relationship:
Phone:
Personal Reference:
Relationship:
Phone:
Personal Reference:
Relationship:
Phone:
