Please use your web browser's printer icon to print this application. When completed, sign and date both pages and fax to the location nearest you. All of America's Financial Choice's locations are listed on the third page.
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Credit Application |
| Applicant(s) Must Be 18 Years or Older |
| 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): $__________.00 |
| Have Direct Deposit? Yes No Any Wage Garnishments? Yes No |
| Other Income |
|---|
| Other Income: $__________.00 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 |
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| Nearest Relative: ____________________________________________ Relationship: _______________ Phone: ____________________ |
| Other Relative: ____________________________________________ Relationship: _______________ Phone: ____________________ |
| Personal Reference: ____________________________________________ Relationship: _______________ Phone: ____________________ |
| Personal Reference: ____________________________________________ Relationship: _______________ Phone: ____________________ |
| X______________________________________________________________ Applicant Signature Date: |
| Arbitration. Arbitration is a means for legal matters between parties to be resolved by a neutral arbitrator rather than a court. America's Financial Choice ("we", "us" and "our") has a policy of arbitrating all claims, demands, and disputes which cannot be resolved in a small claims tribunal, including the scope and validity of this arbitration provision and any right you may have to participate in an alleged class action (hereinafter, "Dispute(s)"). All consumer loan agreements contain another arbitration provision that supercedes this arbitration provision and governs the resolution of Disputes. However, if you do not enter into a consumer loan agreement with us, then this provision governs the resolution of Disputes. You agree that Y OU ARE WAIVING YOUR RIGHT TO HAVE A TRIAL BY JURY to resolve Disputes against us. The Federal Arbitration Act governs this arbitration provision. If any party has a Dispute, they must notify the others in writing of the Dispute. You have the right to select any of the following arbitration organizations, which will govern the arbitration under its consumer rules: American Arbitration Association (1-800-778-7879) http://www.adr.org, J.A.M.S./Endispute (1-800-626-5267) http://www.jamsadr.com or National Arbitration Forum (1-800-474-2371) http://www.abr-forum.com, and you will be responsible for you own expenses associated with the arbitration, including the filing, administrative, hearing, and arbitrator's fees ("Arbitration Fees"). If the arbitrator does not render a decision or an award in your favor resolving the Dispute, then the arbitrator will require you to reimburse us for our Arbitration Fees, not to exceed the amount that would have been assessed as court costs if the Dispute had been resolved by a state court with jurisdiction. Each party will be responsible for its own attorney's fees, if any. Any appeal of a judgment from a small claims tribunal shall be resolved by binding arbitration. The arbitrator shall not conduct class arbitration. The arbitration hearing will be conducted in the county in which this Credit Application was signed. Credit Check. We will perform a credit check. The information you have provided in and with this Credit Application will be sent to one or more credit agencies for a search of their databases and for a determination as to whether or not you satisfy our credit criteria. The databases used by such credit agencies are national databases of consumers who have a record of transactions with certain lending institutions. You agree to and authorize such searches and credit analysis. Release of Information. You authorize complete verification of all information that you have provided and acknowledge that this information may be used to verify certain past and/or current credit or payment history information from third party source(s). We may contact any person or company listed above and you fully release all parties from any liability for any damages that may result. Your application may be rejected if any information provided is found to be false or inaccurate. Notice. The federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age (provided the applicant has the capacity to enter into a binding contract); because all or part of the applicant's income derives from any public assistance program; or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act. The federal agency that administers compliance with this law concerning us is the Midwest Region, Federal Trade Commission, 55 East Monroe St., Suite 1860, Chicago, IL 60603-5701 or Federal Trade Commission, Equal Credit Opportunity, Washington DC 20580. By signing below and submitting this Credit Application you are certifying that all information contained herein is accurate. You agree that this Credit Application, and any supporting documentation provided with it, is our property. You represent that you are not a debtor under any proceeding in Bankruptcy and do not intend to file a petition under any bankruptcy code. You agree to the Arbitration Provision. |
| X______________________________________________________________ Applicant Signature Date: |
| Please sign and date both pages and fax to the location where you would like your loan application processed. | |||
|---|---|---|---|
| Chicago - Loop/Downtown 570 W. Roosevelt | Phone: 312-461-9999 | fax: 312-469-9850 | |
| Chicago - North 1150 W. Belmont | Phone: 773-472-5626 | fax: 773-472-1429 | |
| Chicago - Northwest 3555 W. Irving Park | Phone: 773-866-1400 | fax: 773-866-2117 | |
| Chicago - Northwest 4016 N. Cicero | Phone: 773-545-2700 | fax: 773-545-5086 | |
| Chicago - West 6 N. Austin | Phone: 708-660-0699 | fax: 708-660-0399 | |
| Chicago - South 10302 S. Halsted | Phone: 773-881-8400 | fax: 773-881-8742 | |
| Calumet City: 667 River Oaks Dr. | Phone: 708-891-2434 | fax: 708-891-2510 | |
| Dolton: 1107 E. Sibley | Phone: 708-201-0668 | fax: 708-201-1394 | |
| Belleville: 1630 Carlyle Ave. | Phone: 618-235-9999 | fax: 618-235-8680 | |
| Centralia: 1023 W. Broadway | Phone: 618-533-7000 | fax: 618-533-3169 | |
| Champaign: 821 Bloomington Rd. | Phone: 217-352-1200 | fax: 217-352-1217 | |
| Decatur: 2891 North Water Street | Phone: 217-876-0123 | fax: 217-876-9741 | |
| Du Quoin: 799 S. Washington St. | Phone: 618-542-2000 | fax: 618-542-6126 | |
| Effingham: 1310 S. Banker | Phone: 217-342-4000 | fax: 217-342-4118 | |
| Granite City: 3717-G Nameoki Rd. | Phone: 618-451-0595 | fax: 618-451-0596 | |
| Litchfield: 14-1 Litchield Plaza | Phone: 217-324-5400 | fax: 217-324-5442 | |
| Mattoon: 221 Lake Land Blvd. | Phone: 217-235-6999 | fax: 217-235-6748 | |
| Mt. Vernon: 3216 Broadway | Phone: 618-242-4400 | fax: 618-242-4905 | |
| Olney: 1214 E. Main St. | Phone: 618-392-5626 | fax: 618-392-5629 | |
| Sparta: 1701 N. Market. Suite E | Phone: 618-443-4334 | fax: 618-443-4423 | |