Rapid Cash Advance

Referral Coupon

This page is for Florida Residents only!

All other States click here!

To apply for a cash advance, please fill out the form below completely.
You will be contacted by a customer service representative
and will be given instructions on how to complete the process.

This page uses a secure Internet connection ( SSL ) for protection of your information.

NOTE:�FIELDS ARE REQUIRED.

Section 1 - Personal Information

Social Security Number:

( xxx-xx-xxxx )

E-Mail Address:

Name Prefix:

First Name:

Middle Name:

Last Name:

Date of Birth:

Driver's License Or State ID Number:

Which State Was The License Or ID Issued:

Home Address:

( No P.O. Boxes )

City:

State:

Zip Code:

- ( xxxxx-xxxx )

How Long Have You Been At This Address?:

( Years ) - ( Months )

Do You Rent Or Own This Residence?:

( Rent ) - ( Own )

Home Phone Number:

- - ( xxx-xxx-xxxx )

Cellular Or Wireless Phone, Or Pager Number:

- - ( xxx-xxx-xxxx )

Home Fax Machine Number:

- - ( xxx-xxx-xxxx )

Do You Have Any Unpaid Cash Advances?:

( Yes ) - ( No )

Are You Currently Filing Or Considering Filing For Bankruptcy?:

( Yes ) - ( No )

Section 2 - Employment Information

Name of Current Employer:

Job Title / Function:

How Long Have You Been Employed There?:

( Years ) - ( Months )

Employer's Address:

City:

State:

Zip Code:

- ( xxxxx-xxxx )

Work Phone Number:

- - ( xxx-xxx-xxxx ) - Extension: ( If Any )

Work Fax Machine Number:

- - ( xxx-xxx-xxxx )

Supervisor's Name Prefix:

Supervisor's First Name:

Supervisor's Last Name:

Supervisor's Job Title / Function:

Supervisor's Phone Number:

- - ( xxx-xxx-xxxx ) - Extension: ( If Any )

Are Your Paychecks Direct Deposited?:

( Yes ) - ( No )

How Much Do You Take Home On Each Paycheck?:

$ ( To The Nearest Dollar )

How Often Are You Paid?:

What Are Your Next Two Pay Dates?:

Please note that your next pay date should not be less than 7 days,
and not be more than 30 days away.

Advance Amount You Are Requesting:

Please note that if the Advance Amount you are requesting exceeds the advance amount you qualify for,
you will be offered the maximum advance amount you did qualify for.

Section 3 - Banking Information

Name of Bank:

Bank's Address:

City:

State:

Zip Code:

- ( xxxxx-xxxx )

Bank's Phone Number:

- - ( xxx-xxx-xxxx )

How Long Have You Had This Account Open?:

( Years ) - ( Months )

Bank Routing Number:

( Located on Personal Check )

Bank Account Number:

( See Sample Check Below )

Section 4 - Reference Information

Reference #1 Information

Name Prefix:

First Name:

Last Name:

Relationship:

City:

State:

Phone Number:

- - ( xxx-xxx-xxxx )

E-Mail:

Reference #2 Information

Name Prefix:

First Name:

Last Name:

Relationship:

City:

State:

Phone Number:

- - ( xxx-xxx-xxxx )

E-Mail:

Reference #3 Information

Name Prefix:

First Name:

Last Name:

Relationship:

City:

State:

Phone Number:

- - ( xxx-xxx-xxxx )

E-Mail:

Section 5 - Cash Advance Agreement

I have read, understand, and agree to ALL of the disclosures, terms, and conditions listed in
the Rapid Cash Advances, Inc Legal Agreement. ( You Must Select One )
To view the Rapid Cash Advances, Inc Legal Agreement, Click Here.

I certify that all of the information provided herein is true and complete for the purpose of obtaining a Cash Advance. By applying for a Cash Advance from Rapid Cash Advances, Inc, I authorize the company, its representatives, agents, and assignees, to verify the information and the credit references I have provided, and to obtain any other credit information both now and in the future for any legitimate purpose associated with this application or the Cash Advance, including but not limited to reviewing, renewing, or collecting on the Cash Advance. I understand that if Rapid Cash Advances, Inc approves this application, the terms and conditions applicable to the Cash Advance will be those set forth in the Rapid Cash Advances, Inc Legal Agreement, which I agree to have read before submitting this application. I understand that I must update any of the above information at the request of Rapid Cash Advances, Inc if any of the information changes during the life of the Cash Advance. And finally, I understand that Rapid Cash Advances, Inc shall retain all of the information provided herein whether or not the application has been approved.

Truth-In-Lending Act Disclosure
As required by the Truth-In-Lending Act, all fees associated with this Agreement are required to be expressed as an Annual Percentage Rate(APR). This requirement provides uniformity among various credit sources, allowing you to compare rates and make the choice that is right for you.

The following table discloses this information as it pertains to this Agreement based on the information provided above.

Due Date	Length of Advance	Advance Amount	Finance Charge	Amount Due	Annual Percentage Rate (APR)

Electronic Signature
Please enter your Full Name and Social Security Number below as part of your Electronic Signature.
This must match the information entered above in Section 1 exactly.

In accordance with the Electronic Signatures in Global and National Commerce Act , by typing my name in the signature box below I understand that it will be considered as legally valid and binding as a written signature. It also acts to certify that the information supplied by me above is true and correct to the best of my knowledge.

Full Name:

Social Security Number:

( xxx-xx-xxxx )

Reference Number:

( For Internal Use Only )