AMOUNT REQUESTED $ STORE NAME

STORE PHONE# STORE SALES REP

STORE FAX#

DO YOU HAVE A CHECKING ACCOUNT THAT HAS BEEN ACTIVE FOR 90 DAYS

YES NO

DO YOU MAKE AT LEAST $1000 MONTHLY INCOME DEPOSITS INTO THIS CHECKING ACCOUNT

YES NO

HAVE YOU HAD INSUFFICIENT FUNDS OR OVERDRAFT CHARGES IN THE LAST 30 DAYS

YES NO

HAVE YOU BEEN WITH YOUR CURRENT EMPLOYER FOR AT LEAST 6 MONTHS

YES NO

HAS YOUR PHONE BEEN DISCONNECTED IN THE PAST 5 MONTHS

YES NO

APPLICANT INFORMATION

FIRST NAME MIDDLE NAME

LAST NAME DATE OF BIRTH

SOCIAL SECURITY# OR ITIN#

HOME STREET ADDRESS APT #

CITY ST ZIP CODE

MONTHS AT THIS ADDRESS OWN or RENT

DRIVERS LICENSE OR GOV ID # STATE OF ISSUE

HOME PHONE # CEL #

EMAIL ADDRESS

EMPLOYER NAME MONTHS WITH EMPLOYER

EMPLOYEER PHONE#

EMPLOYER STREET ADDRESS

CITY STATE ZIP

DOES THIS EMPLOYER USE DIRECT DEPOSIT YES NO

WEEKLY YES NO

BI-WEEKLY YES NO

MONTHLY YES NO

TWICE-MONTHLY YES NO

EXACT DATE OF YOUR NEXT PAYDAY NET MONTHLY INCOME (AFTER TAXES)

TYPE OF EMPLOYMENT:

EMPLOYED

SELF-EMPLOYED

SOCIAL SECURITY

MILITARY

DISABILITY

ALIMONY

BANK NAME: CHECKING ACCT#

ROUTING # CREDIT CARD #   

NAME ON CARD EXP CCV

FIRST REFERRENCE

FIRST NAME LAST NAME

EMPLOYER

CITY STATE ZIP

PHONE WITH AREA CODE

SECOND REFERRENCE

FIRST NAME LAST NAME

EMPLOYER

CITY STATE ZIP

PHONE WITH AREA CODE

BY SIGNING BELOW, I HERBY SWEAR (1) CERTIFY THAT ALL INFORMATION I HAVE PROVIDED ON THIS APPLICATION OR IN CONNECTION HEREWITH IS TRUE AND CORRECT AND COMPLETE. RESOURCE FINANCIAL MAY CONTACT ANY PERSON OR COMPANY I HAVE LISTED ABOVE AND I FULLY RELEASE ALL PARTIES FROM LIABILITY OR DAMAGE THAT MAY RESULT. (2) I UNDERSTAND THAT THIS APPLICATION IS SUBJECT TO APPROVAL BY RESOURCE FINANCIAL AT ITS OFFICE IN THE STATE OF UTAH AND THAT PAYMENTS ARE TO BE REMMITED TO UTAH. IF WE OFFER YOU A LEASE OR PAYMENT AGREEMENT WE WILL CONSIDER THE BANK INFORMATION PROVIDED BY YOU AS ELIGIBLE FOR US TO PROCESS PAYMENT AGAINST. IN ADDITION, AS PART OF OUR INFORMATION PROCESS WE MAY DETECT ADDITIONAL BAK ACCOUNTS UNDER YOUR OWNERSHIP.