Application
In this Advance Application (herein referred to as the "Application"), the words "you" and "your" mean the Applicant identified below. The words "we," "our," "us," and "The Cash Store" mean Cottonwood Financial Ltd.
Red Labels represent REQUIRED fields.
Applicant Information
Name (Last, First, Middle)
Social Security #
Driver License / ID
Date of Birth (MM/DD/YYYY)
Address
 Apt #
P.O. Box Address
City
State
 Zip
 Own/Rent/Other
 How long at Address?
Home Phone Number
 Home Phone is in Whose Name?
Mobile Number
Alternate Number
E-mail: 
Income Information *
Employment Type
 Employer
 Employer Phone Number:
 Position
Employer Address:
Employer City / State / Zip
Length of Employment
Years Months 		Pay Frequency
Last Date Paid
 Next Date Paid
Take Home Pay*
 Direct Deposit
 Wage Garnishment
 Day of Week Paid
*Alimony, child support or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.
Additional Income Information * (Complete only if you want this income to be considered for credit purposes)
Source's Name
 Social Security #
 Source's Address / City / State / Zip (if different from above)
Employment Type
 Employer
 Employer Phone Number:
 Position
Employer Address:
Employer City / State / Zip
Length of Employment
Years Months 		Pay Frequency
Last Date Paid
 Next Date Paid
Take Home Pay*
 Direct Deposit
 Wage Garnishment
*Alimony, child support or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.
Bank Information
Bank Name:
 Checking Account #:
 How Long Has It Been Open?
Years Months
Personal References (We will not contact your references to qualify your loan)
Personal Reference - Nearest relative not living with you
Name

 Relationship
Street Address
 Apt. #
City,State, Zip
Home Phone Number
Personal Reference
Name
 Relationship
Street Address
Apt. #
City, State, Zip
Home Phone Number
How Did You Hear About The Cash Store?
Newspaper Radio Flyer/Handout Friend Internet Direct Mail Billboard Store Sign
Television Yellow Pages Other (explain) 
Do you want to visit The Cash Store nearest your home or your work?
Home  Work  No Preference
Can we contact you upon receipt of this application?
Yes No If yes, what is the best to reach you? Home Number Mobile Number
Arbitration
Arbitration is a means for legal matters between parties to be resolved by a neutral arbitrator rather than a Court. The Cash Store has a policy of arbitrating all claims, demands, and disputes which cannot be resolved in a small claims tribunal, including the scope and validity of this arbitration provision and any right you may have to participate in an alleged class action (hereinafter “dispute(s)”). All customer agreements contain another arbitration provision that supersedes this arbitration provision and governs the resolution of disputes. However, if you do not enter into a customer agreement with us, then this arbitration provision governs the resolution of disputes. You agree that YOU ARE WAIVING YOUR RIGHT TO HAVE A TRIAL BY JURY to resolve disputes against us, our agents and/or owners. The Federal Arbitration Act governs this arbitration provision. If either party has a dispute, they must notify the other in writing of the dispute. You have the right to select any of the following arbitration organizations, which will govern the arbitration under its consumer rules: American Arbitration Association (1-800-778-7879) http://www.adr.org, J.A.M.S./Endispute (1-800-626-5267) http://www.jamsadr.com, or National Arbitration Forum (1-800-474-2371) http://www.arb-forum.com, and we will advance all of the expenses associated with the arbitration, including the filing, administrative, hearing and arbitrator’s fees. You will be responsible for your attorney’s fees, if any. Any appeal of a judgment from a small claims tribunal shall be resolved by binding arbitration. The arbitrator shall not conduct class arbitration. The arbitration hearing will be conducted in the county in which this Application was signed.
Privacy Policy

Important Information - Please click here to view and print Privacy Policy
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Marketing Information (Optional)**
Total Household Income (Include all wage earners in the home):
Educational Background:
How many dependents at home:
How far do you LIVE from our store?
How far do you WORK from our store?
Which radio station do you listen to?
**The information you provide in the Marketing Information section is purely voluntary on your part. The information you provide will assist The Cash Store to better serve you. The Cash Store does not use your responses in the Marketing Information section as a part of the credit decision process during your advance request.
Read Before Signing

You agree that you have read and understood all the above statements, including the Arbitration Provision.

You certify the information supplied by you on this form is true and correct. You authorize verification of the truthfulness of all information contained herein, including contact with any person or firm listed above, and fully release all parties from all liability for any damage that may result. Any false statement made above shall be sufficient basis for rejection. You certify that you have read and understand the above statement.

You certify that you have received, reviewed and understand Cottonwood Financial's Privacy Policy and Notice.

WE MAY REPORT INFORMATION ABOUT YOUR ACCOUNT TO CREDIT BUREAUS. LATE PAYMENTS, MISSED PAYMENTS, OR OTHER DEFAULTS ON YOUR ACCOUNT MAY BE REFLECTED IN YOUR CREDIT REPORT.
I verify that I have read the above terms and conditions
Security
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