SSN:   - - First Name:     MI:   Last Name:   Address:   City:   State:   AE AK AL AR AS AZ CA CO CT DC DE FL GA GU HI IA ID IL IN KY LA MA MD ME MI MN MS MT NC ND NE NH NM NJ NV NY OH OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY   ZIP:  Daytime Phone:   - - This form is required to provide and update your banking information so that we can process your loan. Please fill out the information about your Debit/Bank/Credit Card. If you need to update your deposit/withdrawal information please click here. Be sure to check the agreement box at the bottom of this page. Card Number:   Cardholders Name:   Expire Date:  Month:  01 02 03 04 05 06 07 08 09 10 11 12   Year:  2003 2004 2005 2006 2007 2008 2009 2010 2011 Which Card?:   MasterCard Visa ....................................................... Please check here first:   I have read and agree to the conditions as described below. The abovesigned, for valuable consideration, hereby promises to pay to the order of A-1 Premium Budget, Inc. (hereinafter referred to as "A-1 Premium Budget") all sums advanced to the abovesigned from time to time, and in such amounts received from A-1 Premium Budget, together with all finance charges and costs, if any. The abovesigned hereby authorizes and empowers A-1 Premium Budget, its assigns, successors, and all current or future agents, tocharge to my Debit Card / Check Card / Credit Card identified above, including the withdrawal of any and all amounts present in this account until all obligations under this agreement have been satisfied. The abovesigned further empowers A-1 Premium Budget, its assigns, successors, and all current or future agents, to act on my behalf in the completion of all present and future loan documents including but not limited to the completion of Loan Agreements and the endorsement of Loan Checks as required. This authorization shall remain in full force and effect until canceled in writing by the abovesigned. No such cancellation shall be effective so long as funds remain due and owing to A-1 Premium Budget under this agreement. The loan is designed as a short-term cash flow solution and not designed as a solution for longer term financial problems; additional fees may accrue if the loan is rolled over; and credit counseling services are available to consumers who are experiencing financial problems. YOU MUST ANSWER ALL QUESTIONS FOR THIS TO BE PROCESSED