Cash Advance Application | Georgia Capital Finance Inc

Installment Loan Application

Amount $ Requesting:

Purpose of Loan:

Referred By:

We offer referral fees, after a customer has made their first payment.

Are you Active Duty Military or a dependent?

Yes
No

Due to changes in the Military Lending Act regulations, we regret that we are no longer able to make loans to members of the Armed Forces serving on active duty or active Guard or Reserve duty or the Spouse or Dependent of such a person.

Customer Information

Title:

Name

First

Middle

Last

Birth Date

Gender:

Male
Female

Home Phone:

Cell Phone:

Email

Physical Address:

Physical Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Mailing Address: (if different from your physical)

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

How long have you lived in your given address?

0-1 Year
1-2 Years
3-4 Years
5+ Years

Landlord's Name (if renting):

Landlord's Phone:

Marital Status:

Single
Married
Other

Spouse's Name

Spouse's Phone:

Employment Information

Present Employer *

Present Employer

*If you are on a fixed income, please use SSI as your employer and title. Please use your personal information for the duration of the employment questions. If you have questions, please call our office during normal business hours.

Work Address:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Work Phone:

Position/Title

Years At Position

Supervisor's Name:

Pay Schedule

Weekly
Bi-Weekly
Monthly

Monthly Income

Bring home or Net Pay

Next Pay Date

mm/dd

Previous Employer

Monthly rent/mortgage

Monthly Auto Expense

Other Sources of Income and Amounts:

Personal References

2 Friends & 2 Family (minimum of 2)

Reference 1

First

Last

Reference 1

Relationship

Reference 2

First

Last

Reference 2

Relationship

Reference 3

First

Last

Reference 3

Relationship

Reference 4

First

Last

Reference 4

Relationship

Financial History

Have your ever filed Bankruptcy?

No
Yes

If yes, what year?

If yes, CH 7 or 13?

If yes, current status/last action date?

Have you had contact with an attorney to consider filing bankruptcy within the last 90 days?

No
Yes

Terms and Conditions

YES

Everything that I have stated on this form is correct to the best of my knowledge and belief. I understand that you will retain this form whether or not service is provided. I authorize you to obtain such information as you may require concerning the statements made in this application, including my income and employment history, and to obtain information about me from consumer reporting agency. I hereby authorize any third party to release any information that you may require. You are authorized to release any information requested by another party who has a legal right or to whom I may authorize to receive such information. I have provided this information for the purpose of inducing you to provide me the services offered by the company. By submitting this information, Georgia Capital Finance Inc, is released from any and all liability for any damages arising out of this request for service and this application, or any subsequent transaction. I have carefully read each of the answers to the foregoing questions and hereby warrant that all information provided herein is true and correct, with full knowledge that it will be relied upon by you in agreeing to provide the service for which I have requested.

Customer Signature:

Clear Signature