EasypayFinancial
Customer Application

What form of ID will be provided to the merchant?

Name

Home Address

Contact Information

This must be the applicant’s mobile phone number. This number is required to receive text messages.
This email address must be accurate and belong to the applicant since we send copies of contracts and payment information to the address provided.

Identification

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Housing and Employment Status

"Employer Name" is required (no generic filler). If self-employed, the business name is required (not "self"/applicant’s name). For other income (e.g. Social Security, SSI, Pension, Disability, etc.) the "Other" box must be checked and the source entered in "Employer Name".
Ext:

Note: Alimony, child support or separate maintenance income need not be revealed if you do not wish to have it considered as a basis for repaying this obligation.

Checking Information

Credit/Debit Card Information

Note: If you are using your mobile device and cannot enter your CC #, please use your tab arrow to access the field

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References**

Please provide one reference which must be a relative.

Signature

I Acknowledge and Agree that I have read the appropriate State Law Disclosures and Terms and Conditions of this Credit Application of this Credit Application.

Not available to customers in CT, NY and VT. Financing offered to residents in AL, AR, CO, DC, FL, GA, HI, IA, IN, LA, MA, MD, ME, MI, MN, MS, MT, NC, NE, NJ, OH, OK, RI, SC, SD, TN, TX, WV, WY and District of Columbia is made by Transportation Alliance Bank, Inc., dba TAB Bank, which determines qualifications for and terms of credit. Financing in all other states is administered by EasyPay Finance.