First Name:     Last Name:

SIN Number:   Contact Phone:

I want to: Get a new loan Get maximum allowable loan               Amount: 120 Dollars 160 Dollars 200 Dollars 240 Dollars 280 Dollars 320 Dollars 360 Dollars 400 Dollars 440 Dollars 480 Dollars

My next 2 pay dates are: -- dd/mm/yy  -- dd/mm/yy

To complete this transaction I would (please select from FAX or Visit):

Fax current bank statement & pay stub to 416-259-2202

Visit your location at: Lakeshore and Mimico

I understand that Totally Cash Inc. is relying on this disclosure statement to determine my eligibility for a loan.

I do not intend to file bankruptcy or make a creditors proposal before this loan is repaid. Should I make a creditors proposal or file bankruptcy until this loan remains unpaid in whole or part, I will direct my trustee to honor the wage assignment that I have signed on this date and make payment directly to Totally Cash Inc.

I agree to allow Totally Cash Inc. to obtain and share my personal records and credit information regarding this loan, with any third party, including the people working in Payroll Dept. or Human Resources Dept at my employment.

I warrant that the information contained in this application is true, accurate and complete.

I hereby give permission to verify the above information for a credit decision based on the verified information.

Additional Information: