Payday Loan Application | Continental Currency Services

Enter your reference information

Name of Nearest Relative or Friend *

FirstLast

Phone Number of Relative or Friend

Address of Nearest Relative or Friend *

Street AddressCityStateZip Code

1. Have you ever foreclosed, assigned or transfered property for the benefit of creditors?*

Yes
No

Date

please specify $

2. Are there any insatisfied judgments against you?*

Yes
No

3. Do you have any post-dated checks outstanding?*

Yes
No

please specify $

4. Do you presently have a Payday Loan or deferred deposit with CCS or any other lender?*

Yes
No

5. Have you ever filled for bankruptcy?*

Yes
No

please specify $

*

I have read and agree to the Continental Currency Services Terms of Service and Continental Currency Services Privacy Policy. I submit to Continental Currency Services, Inc. (CCS) this application for the purpose of inducing CCS to enter an agreement to defer the deposit of a check. I certify that this application represents a complete and correct statement of the matters shown as of the date of my execution. I have not omitted any pertinent information. I have voluntarily provided all information. I will notify CCS promptly, in writing, of any material unfavorable change in this information. In the absence of such notice, CCS may consider this a continuing application and one that remains correct. CCS is authorized to contact credit-reporting agencies and all other sources for the purpose of verifying any information stated herein or at any time furnished by me to CCS. I understand this application and any other document furnished to CCS shall be CCS’ property. From time to time, I may give CCS a post-dated check in payment of a Payday Loan Contract. On the date of my deferred deposit, CCS is authorized and requested to submit my check for deposit. In the event any check given by me in payment of a Payday Loan Contract is dishonored or does not clear my bank, CCS is authorized to initiate legal action, following default, to collect all monies due including court costs, expenses, and returned-check charges as may be authorized for recovery under any Payday Loan Contract I enter with CCS. ARMED FORCES ACKNOWLEDGMENT: Borrower is NOT a regular or reserve member of the Army, Navy, Marine corps, Air Force, or Coast Guard, serving on active duty under a call or order that does not specify a period of 30 days or fewer OR a dependent of such a member. Borrower is NOT a dependant of a member of the Armed Forces on active duty as described above, because Borrower is not a member’s spouse, a member’s child under the age of eighteen years old, nor is Borrower an individual for whom a member provided more than one-half of Borrower’s financial support for 180 days immediately preceding today’s date.

Continental Currency Services

Continental Currency Services, INC.

Application for Payday Loan / Deferred Deposit Program

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