Step 1: Personal Information
Loan Amount
Full Name
 
First Name
M.I.
Last Name
Gender
Male | Female
Address
 
Street
 
 
Street 2
 
 
City
State
Zip
Housing Status
Own | Rent
Duration at Address
Years Months
Email
Date of Birth
 
Month
Day
Year
Home Phone
- -
Cell Phone
- -
Preferred Contact Time
Morning | Afternoon | Evening
Social Security Number
- -
Drivers License State
Drivers License No
Are you a US citizen?
Are you an active member of the military?
Warning: It is important to fill out this form accurately. Knowingly making a false statement on a credit application is a crime
Step 2: Employer Information
Income Type
Employer Name
Employer Address
 
Street
 
 
Street 2
 
 
City
State
Zip
Employment Type
Job Title
Work Phone
- - Ext.
Hire Date
 
Month
Day
Year
Duration with current employer
Years Months
Step 3: Payroll Information
How do you receive your paycheck?
Paycheck amount per pay period
$ .00
How often do you receive a paycheck?
Net Monthly Income
 
Net monthly income after taxes
Last Payment Date
Next Payment Date
Bank Name
Account Type
Checking Account | Savings Account
ABA (Routing) Number
Account Number
Account Open For
Years Months
Step 4: Reference Information
Reference 1
 
First Name
Last Name
Contact Number
- -
Relationship
Reference 2
 
First Name
Last Name
Contact Number
- -
Relationship
Please be patient after submitting your application, processing could take as much as five minutes.
 
 

For questions or complaints regarding payday loans, you may call our customer service at 201-676-2248 or email us at support@dollarpremier.com. If your problem cannot be resolved by speaking with us and the nature of the complaint is something other than a high rate of interest or lack of funds to pay the loan, then you may call the Department for regulatory relief, if warranted.

Utah residents may contact the Utah State Department of Financial Institutions at 801-538-8830.

Residents of other states may contact the regulatory agencies of the states in which they reside.