New Form - Flash Pay

1

Your details

We need your contact info to send the loan agreement and payment confirmation.

First name*

Last name*

Email address*

Phone / WhatsApp*

Business name (Optional)

Address*

2

Bill details

Tell us exactly who to pay and how much. Double-check all details — a wrong payment cannot be reversed.

Bill type*

Bill amount ($)*

Payee / vendor name*

Bill No*

Payee bank routing #*

Payee bank account #*

Special instructions

Invoice / bill copy (optional — speeds up processing)

3

Your repayment card

Your card details are used to charge repayment. Charged as a regular purchase — you earn your full points, miles, or cash back.

🏆

Regular purchase — not a cash advance. You earn your full card rewards on every dollar charged.

Card network *

Card number*

💳

🔒

Transmitted over 256-bit SSL — never stored in plain text

Cardholder name*

Expiry date*

CVV / Security code* 3 digits on back (Visa/MC) / 4 on front (Amex)

Billing ZIP code*

4

Identity verification

Required to validate the loan agreement. Please select your ID type and upload a clear photo of the document.

Date of birth*

Last 4 of SSN*

Select ID Type *

Driver's LicenseState IDPassport

UPLOAD DOCUMENT (FRONT)

Click to upload JPG, PNG, or PDF

🔒 ID transmitted via 256-bit SSL encryption. Used for verification only.

Reference ID: Generating...

5

Review & confirm

Please verify your details below before reading the agreement.

Contact Details

Name: --

Business: --

Email: --

Phone: --

Bill Summary

Payee: --

Amount: --

Bill Type: --

⚠️ PLEASE READ AND SCROLL TO THE BOTTOM TO ENABLE THE ACCEPTANCE CHECKBOX.

Loan Agreement & Terms

This Loan Agreement ("Agreement") is made between the Applicant and Flashpay. By proceeding, you acknowledge and agree to the following terms:

Loan Purpose: Flashpay provides a temporary loan to pay your specified bill directly to the vendor.
Repayment: You authorize Flashpay to charge your provided payment card for the total bill amount plus any applicable service fees.
Accuracy: You are responsible for the accuracy of the Payee information. Flashpay is not liable for payments made to incorrect accounts provided by you.
No Chargebacks: You agree not to dispute or initiate chargebacks for these transactions with your bank.
Verification: You confirm that the identity documents provided are valid and belong to you.

By clicking submit, you acknowledge that you have Read full agreement.

✓ I have read and agree to the Loan Agreement.

6

Digital Signature

Please sign within the box to authorize this agreement.

Clear and Re-sign if needed.

🔒 SSL encrypted

📝 Agreement sent before charge

✅ Proof of payment sent

🕒 Response within 2 hours