Monday October 10, 2005 Federal Banking Holiday

AmeriCash Advance (banks, credit unions, and the Federal Reserve) will be closed on October 10, 2005, in observance of Columbus Day. Customers whose Loan requests are processed on Friday October 7, 2005 will receive funds in their accounts on Tuesday October 11, 2005

Even though AmeriCash Advance offices will be closed on Monday October 10, 2005, all Request Forms may be submitted over the weekend and on the holiday, and will be processed on Tuesday October 11, 2005

A short term advance provides the cash needed to meet an immediate short-term cash flow problem. It is not a solution for longer term financial problems for which longer term financing may be more appropriate. You may want to discuss your financial situation with a counseling service in your community. You will be charged additional fees if you renew/extend the advance.

Currently not providing services to residents of




The amount I am requesting for
my first advance.

First Name

Middle Name

Last Name

Birth Date (mm/dd/yy)

home phone #

cell phone #

Mother's maiden name

Your address (no PO Boxes)

City, State


RentOwn / APT.#

Months at address  

Driver's license #

State Issued

Spouse's Name (if married)

Spouse's SS#    

Your fax #

Select amount currently owed on other cash advances.    

Your email address

work email (if different)

NAME of your Employer

ADDRESS of Employer


Employer main phone # Your work phone/ ext.
Length of employment Are you paid by direct deposit?
Monthly net (take home) income
What are your scheduled pay dates?
If weekly or bi-weekly, what day? 

  Your NEXT TWO pay dates/ AND /

 Please make sure these dates are filled in correctly to reflect your actual pay
dates so we may complete your application process without delay.

Name of bank Bank phone #

Transit Routing Number

Bank Account Number 

Bank Routing /Account Numbers are located on the bottom of your personal check.

Click here for a sample check Months account open 

Due date:

Your next pay date
(up to a maximum 18 days)    
UPON APPROVAL, I authorize AmeriCash Advance LLC  to deposit a cash advance (in the amount that I will be approved for, which I acknowledge may be less than the amount requested) into my bank account and to withdraw the approved advance amount plus the associated fee at the rate of $20 per $100 advanced to me, on the date specified above. I understand and agree the cash advance amount received plus fee is due on my NEXT NEAREST PAY DATE (up to a maximum of 18 days).

I understand I will be contacted by phone at the numbers provided on this application to confirm my approved cash advance amount.

Legal/Disclosure Acknowledgement:
If you acknowledge that you have read the disclosures listed in the Master Agreement, verify by clicking the yes button below to continue.  You may review these documents again by clicking here :Master Agreement (disclosures)   I agree that electronic mail, electronic forms, records, photocopies, and /or facsimile copies of the documents I submit are valid and enforceable as the original.  I agree that by typing my name as my electronic signature, it is acknowledged and understood that it constitutes an acceptance of all terms and conditions of the master cash advance agreement and is valid and enforceable in accordance with the "Electronic Signatures in Global and National Commerce Act"

I agree to maintain an adequate balance and keep my account(s) open to allow all ACH/EFT and/or bank drafts to AmeriCash Advance to occur in a timely manner for the scheduled due date. I further agree and confirm that by submitting completed/ signed internet request forms as a matter of convenience, hereby constitutes the same legal and binding document as providing AmeriCash Advance LLC 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 $25.00 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
that, upon approval, this and all future transactions are made pursuant to the AmeriCash Advance Internet Master Cash Advance agreement (which will be on file with AmeriCash Advance) and is NOT an installment loan that I can make payments on, but is due in full on my next nearest pay date.

I have read, understand, and agree to ALL terms, disclosures, and conditions of the AmeriCash Advance Internet Master Cash Advance Agreement.   


By electronically signing this form I acknowledge that all information provided by me in this application is true and correct and authorize AmeriCash Advance LLC, its successors, and assigns, to verify any and all information contained herein.  Furthermore, I authorize AmeriCash Advance to conduct the EFT transactions and/or bank drafts requested now and in the future, according to all agreements and disclosures listed.
Type your Social Security Number
Please re-type your Social Security # to verify.

Any additional comments, type here:

 For your records, print a copy of your completed application BEFORE submitting.

 Click to SUBMIT your information for processing.

After you submit this application, you will then view the Agreement Signature Page PRINT, SIGN, and FAX with the required verification items. Once these items are received, only then will your approval process will begin. The approval process takes approximately 30 minutes.

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