Ohio: Collection Representative Application

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©2012 Community Choice Financial Inc.™, * 7001 Post Road, Suite 200 * Dublin, Ohio 43016 * 800-837-0381

Customer Notice: Loan services should be used for short-term financial needs only, not as a long-term financial solution. Customers with credit difficulties should seek credit counseling. Ohio License #CC700000, #SM501585, #SL400145

Insight Visa® Prepaid Debit Cards are issued by Republic Bank of Chicago and Urban Trust Bank, FSB, Members FDIC, pursuant to licenses from Visa U.S.A. Inc.

The USA PATRIOT Act is a Federal law that requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. You will be asked to provide your name, address, date of birth, and other information that will allow us to identify you. You may also be asked to provide documentation as proof of identification. Approval is contingent upon successfully passing this mandatory identification confirmation.