Cash Now Salisbury
Regular Secure Online Form
 Ph: 8410 2274

  1. You have been living at the same address for at least 6 months.
  2. You have a current bank account with 3 months bank statements.
  3. You have photo identification.
  4. You have regular income.

To return to the Cash Now Salisbury Web page

Customer Information
First Name:
Last Name:
 
Birth Date:
dd mm yyyy
E-mail:
How did you find out about us?:
ID Type 1:
ID No 1:
ID Type 2:
ID No 2:
Address:
City:
State:
Postcode:
How long at this address:
Home Ph:
 [ xx-xxxx-xxxx ]
Who's name is the telephone listed under:
Fax No:
 [ xx-xxxx-xxxx ]
Work Ph:
 [ xx-xxxx-xxxx ]
Mobile No:
 [ xxxx-xxx-xxx ]
Preferred method of daytime contact:
Employer Information
Employer's Name:
Address :
City:
State:
Postcode:
Employer's Ph:
 [ xx-xxxx-xxxx ]
Payroll Officer's Name:
Your Position:
Take home pay:
 [ $XXXX.xx ]
Date of last pay:
dd mm yyyy
Date of next pay:
dd mm yyyy
Status:
How long with this company:
Frequency of pay:
Hourly rate:
What day do you get paid:
Bank Information
Bank:
Address:
City:
State:
Postcode:
BSB:
  [ xxx-xxx ]
Bank Acc No:
Have you ever claimed bankruptcy:
Were you discharged:
Outstanding wage assignments/garnishees:
Loans outstanding with other payday lender's:
Reference Information
Reference: 1 (not living with you)
Name:
Address :
City:
State:
Postcode:
Ref 1 Ph:
Relationship:
Reference: 2
Name:
Address :
City:
State:
Postcode:
Ref 2 Ph:
Relationship:
Amount of Loan Requested: