Get Started With Your Fast Loan Application Today Tell Us About Yourself "*" indicates required fields CommentsThis field is for validation purposes and should be left unchanged.Loan AmountPlease enter a number greater than or equal to 1.Reason for LoanDate of Birth* MM slash DD slash YYYY Name* First Last Physical Home Address Street Address City State ZIP / Postal Code Is Mailing Address Same as Physical Address? Yes No Mailing Address Street Address City State ZIP / Postal Code Email Address* Cell Phone Number*Best Time to Reach You9:00 AM10:00 AM11:00 AM12:00 AM01:00 PM02:00 PM03:00 PM04:00 PM05:00 PM06:00 PM07:00 PM08:00 PM09:00 PMDo You Rent or Mortgage?* Rent Mortgage Parents Landlord or Mortgage Company NameRent Monthly or Mortgage PaymentAre You a Us Citizen?* Yes No Are You in the Military?* Yes No Type of Income*EmployedSelf EmployedSocial SecurityDisabilityRetirementOccupation*Employer Address* Street Address City State ZIP / Postal Code Net Monthly Income: $*How Often Do You Get Paid?*WeeklyBi-WeeklyMonthlyTwice MonthlyHow Long Have You Been Employed?1 Year2 Years3 Years4 YearsMore Than 5 YearsDo You Have A Secondary Income?* Yes No Type of Income*EmployedSelf EmployedSocial SecurityDisabilityRetirementPlace of Employment*Occupation*Employer Address* Street Address City State ZIP / Postal Code How Often Do You Get Paid?*WeeklyBi-WeeklyMonthlyTwice MonthlyHow Long Have You Been Employed?1 Year2 Years3 Years4 YearsMore Than 5 YearsPlace of Employment Phone Number?Net Monthly Income: $*Last Payday:*Next Payday:*Consent* I have read and understand and accept the terms of the Consent for Electronic Records. By checking here you agree that we may (i) call you at any number provided on your credit application, including your cell phone, with an auto dialer or prerecorded message (ii) write you, via US postal service and/or electronic mail or (iii) contact you by text message or other wireless communication method on any telephone number listed on your application, savings and services we believe may be of interest to you as well as account status information. You may change your preferences at any time by contacting us.Consent to receive Electronic documents: 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 Iberville Credit Corporation. We can give you the benefits of our online 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 online 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 ibervillecredit@yahoo.com. You may request a paper copy even if you withdraw your consent to: ibervillecredit@yahoo.com. Iberville Credit Corporation 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. 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: ibervillecredit@yahoo.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 (including but not limited to the Arbitration Agreement and the Notice-of-Grievance Agreement, each set forth above). 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 (225) 687-4920 or e-mail us at ibervillecredit@yahoo.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.Section BreakUntitledUntitled
