Highland Quick Cash, Inc. 12589 State Rt. 143 Highland, IL 62249 Ph 618-651-1600
CONSUMER INSTALLMENT LOAN APPLICATION (205 ILCS 670/1 et seq)
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
VEHICLE YEAR VEHICLE MAKE VEHICLE MODEL MILEAGE
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.