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Account Information

First Name: Last Name: Email Address: Confirm Email Address: Password: Confirm Password:

Social Security Number: - - Confirm Social Security Number: - - Security Question: Security Answer: Confirm Answer:

Customer Information

Address: Apt, Suite or Unit #: City: ZIP Code: Home Phone: () - Mobile Phone: () - Fax Number: () -

Date of Birth (mm/dd/yyyy): - - User Identification Type: Select Driver's License State ID User Identification State: Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist. Of Columb Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming User Identification Number: How did you hear about us? Select One Television AD Radio AD Print AD Store Location Search Engine Online AD Friend/Relative TeleMarketing Other How long have you lived at your current residence? Yr.   Mo. Do you own or rent your place of residence? Own Rent Other

Income Information

Main sourse of your income: Select Employed Social Security Disability Income Pension Other How often do you receive a paycheck? Weekly - Paid the same day every week Biweekly - Paid same day every other week Semi - monthly - Paid same 2 days every month Monthly - Paid the same day every month Net pay per paycheck: Active bacnk account type? Checking Savings How do you receive your income? Select Direct Deposit Paper Check Cash

Employment Information

Employer Name: Job Title: Work Phone: () -

Extension: Shift: Select First Second Third Swing Other Hire Date: -- 1 2 3 4 5 6 7 8 9 10 11 12 Mo. 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 Yr.

Bank Information

ABA or Bank routing number: ABA or Bank routing number confirmation: Bank checking account number: Checking account number confirmation:

Additional Information

Federal law provides important protections to active duty members of the Armed Forces and their dependents. To ensure that these protections are provided to eligible applicants, we require you to select yes or no below:
1. I am a regular or reserve member of the Army, Navy, Marine Corps, AirForce, or Coast Guard, serving on active duty under a call or order that does not specify a period of 30 days or fewer or dependent of a member of the Armed Forces on active duty. A dependent of a member of the Armed Forces on active duty as described above is the member's spouse, the member's child under the age of eighteen years old, or an individual for whom the member provided more than one-half of his/her financial support for 180 days immediately preceding today's date.
Yes No

2. Is one of the following statements true? (a) You are not married. (b) You are married, but you voluntarily elect to apply for this loan under your individual credit rather than under the joint credit of you and your spouse. (c) You are married and you elect to apply for this loan under the joint credit of you and your spouse, but your spouse does not have any loan outstanding with us.		Yes No
3. Is the following statement true? The amount of this loan - exclusive of finance charges - does not exceed 25% of the gross monthly income that you expect during the term of the loan.		Yes No

Legal Information

CONSENT FOR ELECTRONIC RECORDS Please read this information carefully and, for future reference, either print a copy of this document or retain this information electronically. 1. INTRODUCTION. You are submitting a credit application to B&R Check Holders Online. We can give you the benefits of our on-line service only if you consent to use and accept electronic signatures, electronic records, and electronic disclosures in connection with this transaction (your "Consent"). By completing and submitting an on-line credit application (your "Application"), you acknowledge that you have received this document and have consented to the use of electronic signatures, electronic records, and electronic disclosures in connection with this transaction (collectively "Records"). 2. ELECTRONIC COMMUNICATIONS. You may request a paper copy of any Record by e-mailing B&R Check Holders Online at: service@checkholder.com. You may request a paper copy even if you withdraw your Consent. B&R Check Holders Online will retain the Records as required by law and will provide you a paper copy of any Record at no charge. 3. CONSENTING TO DO BUSINESS ELECTRONICALLY. Before giving your Consent, you should consider whether you have the required hardware and software capabilities described below. 4. SCOPE OF CONSENT. Your Consent and our agreement to conduct this transaction electronically only apply to this transaction. If we receive your Consent, then we will conduct this transaction with you electronically. 5. HARDWARE AND SOFTWARE REQUIREMENTS. To access and retain the Records electronically, you will need to use the following computer software and hardware: An IBM or MAC compatible computer with Internet access and an Internet Browser that meets the following minimum requirements: Mozilla Firefox 1.5 or later versions or Microsoft Internet Explorer 5.01 or later versions. Also, the specific Internet Browser must support at least 128 bit encryption. To read some documents, you will need a PDF file reader like Adobe Acrobat Reader. If at any time during this transaction these requirements change in a way that creates a material risk that you may not be able to receive Records electronically, B&R Check Holders Online will notify you of these changes. 6. WITHDRAWING CONSENT. You may withdraw your Consent at any time and at no charge to you. If you withdraw your Consent prior to receiving the credit transaction, then your withdrawal will prevent you from obtaining an online credit transaction (i.e., a credit transaction obtained over the Internet). To withdraw your Consent, you must e-mail us at: service@checkholder.com. Note, however, that the withdrawal of your Consent will not affect the legal effectiveness, validity, or enforceability of the credit transaction or of any Records that you received electronically prior to such withdrawal. 7. CHANGE TO YOUR CONTACT INFORMATION. You must keep us informed of any change in your e-mail address or your ordinary mail address. To update your address information, either phone us at 877-4-DEPOSIT or e-mail us at service@checkholder.com. 8. AUTHORIZATION, AGREEMENT, AND REPRESENTATIONS. BY CLICKING THE "I AGREE" BUTTON BELOW, YOU CONSENT TO USE AND ACCEPT ELECTRONIC SIGNATURES, ELECTRONIC RECORDS, AND ELECTRONIC DISCLOSURES IN CONNECTION WITH THIS TRANSACTION. YOU ACKNOWLEDGE THAT YOU CAN ACCESS THE RECORDS IN THE DESIGNATED FORMATS DESCRIBED ABOVE, AND YOU UNDERSTAND THAT YOU MAY REQUEST A PAPER COPY OF THE RECORDS AT ANY TIME AND AT NO CHARGE. IF YOU DO NOT GIVE YOUR CONSENT OR IF YOU DO NOT AGREE TO THE TERMS AND CONDITIONS DESCRIBED IN THIS DOCUMENT, THEN CLICK THE "I DO NOT AGREE" BUTTON BELOW. AUTHORIZATION, AGREEMENT, AND REPRESENTATIONS By clicking the "I Agree" button below, you authorize us to verify the accuracy of the information contained in this Credit Application by, among other actions, submitting your application to a consumer reporting agency, calling your employer to confirm employment, calling your residence to confirm a working home phone number, and obtaining your bank account information. If you obtain one or more Transactions from us, you further authorize us to service your Transactions by obtaining information about your location from the contact persons you have listed. By clicking the "I Agree" button below, I represent and warrant that I am not a regular or reserve member of the Army, Navy, Marine Corps, Air Force, or Coast Guard, serving on active duty under a call or order that does not specify a period of 30 days or fewer (or a dependent of such a member). Furthermore, by clicking the "I Agree" button below, you also agree to all the terms of both the Arbitration Agreement and the Notice-of-Grievance Agreement set forth above. Finally, you represent and warrant that all the information contained in this Credit Application is true and correct, that you are not currently a debtor in any bankruptcy proceeding, and that you do not intend to file a bankruptcy petition under any chapter of the U.S. Bankruptcy Code either during the term of a Transaction or within the 90 day period following your repayment of a Transaction.

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I agree that B&R Checkholder may share my personal financial information with non-affiliated companies, as described in B&R Checkholder's privacy policy. For example, if B&R Checkholder cannot provide me the loan or other financial product I have requested, then B&R Checkholder may share my information with an outside company that offers a similar product that may meet my needs.

WARNING ABOUT FRAUD AND IDENTITY THEFT: Attempting to obtain a credit transaction by providing false information, including but not limited to the use of false or altered documents and the use of another person's identity other than your own (Identity Theft), is fraudulent and, in some cases, punishable by law. B&R Check Holders Online reserves the right to report any and all information obtained in connection with a verified fraud attempt to local, state, or federal authorities including the Internet Crime Complaint Center, an FBI-NW3C partnership, for possible investigation and prosecution. For more information about the NW3C and the FBI, please visit www.ic3.gov.