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Secure Application Secure Application

Personal Information  Help
*Requested Amount
*First Name *Last Name
*Street Address Apartment #
*City *State *Zip Code
 
*Months At Address? *Social Security #
   
*Primary Phone Alternate Phone
       
*Email *Verify Email
Alternate Email (Optional)
*Date of Birth
*Driver’s License/State ID # *ID State
*Are you a Home Owner?
Employment Information  Help
*Employer *Income Type
*Employer Phone Extension
   
*Months Employed? *Are you active military?
(or dependent)
*How Often are you Paid
*Scheduled Pay Dates  Select your next two paydates
*Pay Date One (mm/dd/yyyy) Calendar
August 2008
SunMonTueWedThuFriSat
272829303112
3456789
10111213141516
17181920212223
24252627282930
31123456
September 2008
SunMonTueWedThuFriSat
31123456
78910111213
14151617181920
21222324252627
2829301234
567891011
*Pay Date Two (mm/dd/yyyy) Calendar
August 2008
SunMonTueWedThuFriSat
272829303112
3456789
10111213141516
17181920212223
24252627282930
31123456
September 2008
SunMonTueWedThuFriSat
31123456
78910111213
14151617181920
21222324252627
2829301234
567891011
*How do you receive your paycheck?
*Amount of Last Paycheck:
Financial Information  Help
*Type of Account  
Don't have a bank account? Get one now!
*Bank Name *Months with Bank Account?
Sample Check
*ABA/Routing Number *Account Number


Website Terms and Conditions

ReliancePayDayLoans.com TERMS AND CONDITIONS

Last Updated: 7/24/2008

By accessing the ReliancePayDayLoans.com web site and using the services on this site, you agree to be bound by the terms and conditions ("Terms") below. Please read these Terms carefully. If you do not agree to these Terms, do not access or use this web site. The ReliancePayDayLoans.com web site is operated by Patriot Web Marketing, LLC. All references below to ReliancePayDayLoans.com include Patriot Web Marketing, LLC.

Loan Matching Service

ReliancePayDayLoans.com's loan matching service matches consumers with prospective lenders participating in ReliancePayDayLoans.com's direct network of payday loan lenders ("participating lenders"). To use the service, you must complete one or more online application forms that request specific information from you, including, but not limited to, your name, address, telephone number, email address, social security number, banking account information, and employment information. ReliancePayDayLoans.com's collection and use of this information is subject to this site's Privacy Policy. In order to use this web site or the service, you must agree to the separate terms and conditions set forth in the Privacy Policy, which are incorporated herein by reference.

Once a consumer submits the application form(s) to ReliancePayDayLoans.com, ReliancePayDayLoans.com shares your information with one or more participating lenders. By submitting the application form(s), you understand and agree that you are submitting an inquiry about a loan product