Title Application
NAME, LAST                               FIRST                                           MIDDLE                                   
ADDRESS                                                          CITY                                   ZIP                              
YRS & MOS. AT ADDRESS      CURRENT PHONE            NAME PHONE BILLED TO                      CELL PHONE NO.
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        
SPOUSE/CO-SIGNER NAME       ADDRESS                                                       CITY                                 ZIP                                   
EMPLOYER NAME               GROSS PAY                    OCCUPATION                     YRS EMPLOYED
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.
Swansea Quick Cash, Inc. 2708 N. Illinois, Swansea, IL 62226 Ph 618-235-3636

CONSUMER INSTALLMENT LOAN APPLICATION (205 ILCS 670/1 et seq)

Please complete the following Application.  Please do not leave any fields blank.
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