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PayDayHawaii's MicroCredit
Easy as 1 - 2 - 3 !

1 - Membership Application

2 - Virtual Check

3 - Take forms to nearest location, fax to (866) 822-0275, or email.

Membership Application for a PayDayHawaii Micro-Credit Account

(Customers with a Micro-Credit Account may go directly to Virtual Check.)

All information fields are required and must be filled in, except those with *.

Personal Information

Last Name:
 First Name:
 M.I.:
Physical Address:
 City:
 Zip Code:
Mailing Address if Different:*
 		City:*
 		Zip Code:*
At Current Residence Since:
 		Own  Rent Landlord's Name:
Social Security Number:
   Landlord's Phone Number:
Home Phone No:
 		Name of Person Phone is Listed Under:
 		Cellular/Pager No.:*
  Email:*
  
Work Phone No:
 		Hawaii Driver's License/ID No.:
 		ID Expiration Date:

Employment Information

Employer Name:
 		Supervisor's Name:
 		Phone No.:
Address:
 		City:
 		Zip Code:
Position:
    
Monthly Income:
 		Number of Paydays per Month?:
 		Next Payday is:
With Current Employer Since:
 		Is your paycheck directly deposited?  Yes       No 
Other Income Source:**
 		Monthly Amount of Other Income:*
 		**Income from alimony, child support or separate maintenance need not be revealed unless you want us to consider that income in considering your application.

References

Please list the name, address, & phone number of two (2) friends or relatives not living at your address.
Must be Hawaii residents.
Address:
 		Relationship:
 
City:
 		 Zip Code:
 		 Phone No.:
 
Address:
 		Relationship:
 
City:
 		 Zip Code:
 		 Phone No.:
 

Bank Information

Bank Name:
 		Address:
 		 
City:
 		 Zip Code:
 		 Phone No.:
 
With Current Bank Since:
 		Bank  Account No.:
 		Savings: 
-or-
Checking: 
How did you hear about PayDayHawaii?:*
 

Authorization Agreement for Direct Deposits/Debits

PayDayHawaii  I.D. No. 99-0348732

I hereby authorize PayDayHawaii, to initiate credit entries and to initiate, if necessary, debit entries and adjustments for any credit entries in error to my   Checking   Savings (select one)   indicated below and the depository named below, to credit and/or debit the same to such account.
Bank Name & Routing Number: Branch:
City:
Zip:
 Account No:
 
PLEASE READ: I hereby authorize PayDayHawaii, to initiate debit/credit entries to my account for all payments due, including any returned unpaid item fees due, on which the subject of this agreement is drawn and the Financial Institution at which the account is held to debit/credit the same to such account. This authority is to remain in full force and effect until PayDayHawaii and the subject Financial Institution have received written notification from me of its termination in such time and in such manner as to afford PayDayHawaii and the Financial Institution a reasonable opportunity to act on it. I understand that I may cancel this authorization by providing written notice to PayDayHawaii at least thirty (30) business days prior to the payment due date. I further understand that canceling my authorization does not relieve me of the responsibility of paying all amounts due in full.
Name:
 Social Security Number:
 Date:
Signed:  
 
PLEASE READ: I am applying for a Micro-Credit Account and certify that the above information is true and correct.  I agree to notify PayDayHawaii promptly of any material change in this information.  In the absence of such notice, PayDayHawaii may consider this a continuing application for further cash advances.  My signature below authorizes PayDayHawaii to verify the above information. 
Signature: Date:  

Check List for PayDayHawaii Micro-Credit Application --
I am submitting with this application the following supporting documents:

 Bank Statement
 2 Pay Stubs
 Phone Bill
 Hawaii Driver's License or ID
 Virtual Check
  1. Print Form and Fax to PayDayHawaii (866-822-0275)
       -- Or --
  2. Click on the Submit button below.
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