Highland Quick Cash, Inc. 12589 State Rt. 143 Highland, IL 62249 Ph 618-651-1600

INSTALLMENT PAYDAY LOAN APPLICATION

Please complete the following Application.  Please do not leave any fields blank.
NAME, LAST                               FIRST                                           MIDDLE                                   
ADDRESS                                                          CITY                                   ZIP                              
YRS & MOS. AT ADDRESS      CURRENT PHONE            NAME PHONE BILLED TO                      E MAIL
OCCUPATION           GROSS PAY    TAKE HOME PAY  DIRECT DEPOSIT   DAY OF WEEK PAID      WKLY OR MONTHLY
BANK NAME                                           BRANCH (TOWN)                                         
EMPLOYER NAME                 ADDRESS                                       CITY                                 STATE                            ZIP
YRS EMPLOYED         EMPLOYER PHONE     ACTIVE OR RESERVE MILITARY, SPOUSE OR DEPENDENT        
I agree all information on this application is true, complete, and correct to the best of my knowledge.  
I understand that I will be contacted by phone upon submission of this application.
Highland Quick Cash