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Tell Us About Yourself
Social Security Number:
Date of birth:
Home Phone number:
Cell Phone number:
Do you Rent or Own?
Are you a US Citizen?
Are you in the military?
Are you a dependent of someone in the military?
Driver's license number:
What type of income is this?
Where do you work?
How long have you been with this company?
Less than 3 Months
3 months to 1 year
1 to 2 years
3 to 5 years
6 to 10 years
More than 10 years
What is your work number?
How often do you get paid?
Where should we deposit your funds?
What is your bank's ABA / Routing Number?
What is your account number?
What is the name of your bank or credit union?
Is this a checking or savings account?
How long have you had this account?
Less than a year
1 to 2 years
2 to 5 years
5 to 10 years
More than 10 years
Consent to Receive Electronic Documents:
CONSENT FOR ELECTRONIC RECORDS
Please read this information carefully and, for future reference, either print a copy of this document or retain this information electronically.
INTRODUCTION. You are submitting a credit application to Total Loan Company. We can give you the benefits of our online service only if you consent to use and accept electronic signatures, electronic records, and electronic disclosures in connection with this transaction (your "Consent"). By completing and submitting an online credit application (your "Application"), you acknowledge that you have received this document and have consented to the use of electronic signatures, electronic records, and electronic disclosures in connection with this transaction (collectively "Records").
ELECTRONIC COMMUNICATIONS. You may request a paper copy of any Record by e-mailing Total Loan Company at: firstname.lastname@example.org. You may request a paper copy even if you withdraw your Consent. Total Loan Company will retain the Records as required by law and will provide you a paper copy of any Record at no charge.
CONSENTING TO DO BUSINESS ELECTRONICALLY. Before giving your Consent, you should consider whether you have the required hardware and software capabilities described below.
SCOPE OF CONSENT. Your Consent and our agreement to conduct this transaction electronically only apply to this transaction. If we receive your Consent, then we will conduct this transaction with you electronically.
HARDWARE AND SOFTWARE REQUIREMENTS. To access and retain the Records electronically, you will need to use the following computer software and hardware: An IBM or MAC compatible computer with Internet access and an Internet Browser that meets the following minimum requirements: Mozilla Firefox 1.5 or later versions or Microsoft Internet Explorer 5.01 or later versions. Also, the specific Internet Browser must support at least 128 bit encryption. To read some documents, you will need a PDF file reader like Adobe Acrobat Reader. If at any time during this transaction these requirements change in a way that creates a material risk that you may not be able to receive Records electronically, Total Loan Company will notify you of these changes.
WITHDRAWING CONSENT. You may withdraw your Consent at any time and at no charge to you. If you withdraw your Consent prior to receiving the credit transaction, then your withdrawal will prevent you from obtaining an online credit transaction (i.e., a credit transaction obtained over the Internet). To withdraw your Consent, you must e-mail us at: email@example.com. Note, however, that the withdrawal of your Consent will not affect the legal effectiveness, validity, or enforceability of the credit transaction or of any Records that you received electronically prior to such withdrawal (including but not limited to the Arbitration Agreement and the Notice-of-Grievance Agreement, each set forth above).
CHANGE TO YOUR CONTACT INFORMATION. You must keep us informed of any change in your e-mail address or your ordinary mail address. To update your address information, either phone us at 855-222-0209 or e-mail us at firstname.lastname@example.org.
AUTHORIZATION, AGREEMENT, AND REPRESENTATIONS. BY CLICKING THE "I AGREE" BUTTON BELOW, YOU CONSENT TO USE AND ACCEPT ELECTRONIC SIGNATURES, ELECTRONIC RECORDS, AND ELECTRONIC DISCLOSURES IN CONNECTION WITH THIS TRANSACTION. YOU ACKNOWLEDGE THAT YOU CAN ACCESS THE RECORDS IN THE DESIGNATED FORMATS DESCRIBED ABOVE, AND YOU UNDERSTAND THAT YOU MAY REQUEST A PAPER COPY OF THE RECORDS AT ANY TIME AND AT NO CHARGE.
I have read and understand and accept the terms of the Consent for Electronic Records.
By checking here you agree that we may (i) call you at any number provided on your credit application, including your cell phone, with an auto dialer or pre recorded message (ii) write you, via US postal service and/or electronic mail or (iii) contact you by text message or other wireless communication method on any telephone number listed on your application, in order to inform you about special promotions, savings and services we believe may be of interest to you as well as account status information. You may be charged by your wireless provider in order to receive text messages. You may change your preferences at any time by contacting us at
or by calling us at 855-222-0209
WARNING: This loan is not intended to meet long-term financial needs. This loan should be used only to meet short-term cash needs. The cost of your loan may be higher than loans offered by other lending institutions.
**Credit checks, consumer credit reports and other personal data may be obtained by some lenders from Experian, Equifax, Trans Union or through alternative providers.