Application Form

Loan Information

IMPORTANT: Please apply using Borrower's information.

I would like to apply with a co-applicant:

Loan Amount      

Personal Information
 Enter the legal name of the patient:
First Name:   Last Name:   Middle:
 Provide the personal idenity information that matches the patient's name above.
Social Security Number:             Date of Birth:      
Marital Status:   For marketing purpose only.

Physical Address

 Enter the address of the primary borrower: (MUST BE A VALID STREET ADDRESS NO P.O. BOXES)
Street Address:     Apt:
City:   State:   Zip Code:  

Mailing Address (Optional)

Optional: Include a mailing address for billing.
City State: Zip Code:
 Indicate the state the primary borrower has legal residence.
Legal State of Residence:   Time at Residence: Years   Months  

Contact Information
 Approval and application status will be sent to the following.
Email Address:     Home Phone: ( ) -      
Mobile Phone: ( ) -

Financial Information
 Note: Alimony, child support, or separate maintenance income need not be revealed if you do not wish it considered as a basis for payment.
 Enter all amounts as GROSS Monthly values.
Gross Monthly Salary:  
Per Month
Spouse Income:  
Per Month
Child Support:  
Per Month
Retirement Income:  
Per Month
Rental Income:  
Per Month
 Include current living expense.
Living Status:   Rent/Mortgage Monthly    
Enter 0 if no rent or mortgage.

Enter (1) one personal reference below:
Name:   Phone: ( )   -       Relationship:  

Work History
Enter current employment details.
Employment Status:  

Physician Information
I have chosen a physician for my procedure*
Procedure Information
Please select the category that best fits your needs: *
Procedure Type:  
Select Procedure(s): *


The Applicant/Additional Applicant hereby acknowledge and recognize that this is an application for credit. By submitting this application, I(We) have verified that all information submitted on this application is true and correct to the best of our knowledge, as well as allowing Company, and/or its Lender(s) and other 3rd Parties to verify the enclosed information, including, but not limited to, obtaining our credit reports, contacting our employers to verify employment and income, and/or contacting our Physician to verify the type of procedure(s), procedure date, deposit amount, procedure amount, and remit payment upon approval. I(We) understand and agree that the Lender(s) [as defined in the Promissory Note or communicated to me] can furnish information concerning my/our account to consumer reporting agencies and others who may properly receive that information. By providing a telephone number for a cellular phone or other wireless device, I(We) are expressly consenting to receiving communications at that number, including, but not limited to, prerecorded voice message calls, text messages, and calls made by any representatives from Company and/or its Lender(s) and other 3rd Parties. This express consent applies to each such telephone number that I(We) provide to Company and/or its Lender(s) now or in the future and permits such calls regardless of their purpose. These calls and messages may incur access fees from my/our cellular provider. I(We) understand that we may opt out of this authorization by providing written notice to the parties herein. If approved for a revolving account, a credit card will be issued in either the Applicant or Additional Applicant's name only, and it will be sent to the home address on the application. APR’s will vary depending upon credit ratings and/or payment terms that are approved. Credit approvals are valid for a limited time only. Certain fees may apply. By signing, I(We) certify that I(We) have read, agree to, and understand the disclosures herein and I(We) agree to the terms of this application and that a physician staff member may apply on our behalf.

Please read before Continuing.

To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. What this means for you: When you open an account, we will ask for your name, address, date of birth and other information that will allow us to identify you. We may also ask to see your driver’s license or other identifying documents.

I HEREBY ACKNOWLEDGE that I am over the age of eighteen (18) years, and that all of the information set forth in this credit statement is true, accurate and full and complete disclosure thereof. I am providing written consent under the Fair Credit Reporting Act for above client and its partners with whom I am matched to obtain a consumer credit report from a contracted credit bureau. I understand that I am submitting an application for credit, and am consenting to the use of my credit report information. I authorize any holder of this credit application or any person, firm or corporation requested to extend credit there under, (including any employee or agent of any of them) to communicate with my employer in order to verify my employment. I authorize any holder of the Retail Installation Contract, the creditor thereof, or any Attorney, debt collector or collection agency to communicating any and all information concerning this application or debt to any credit reporting agency or other creditor. By providing my email address, I consent to receive electronic information such as monthly billing reminders, statements and collection notices. I also acknowledge that you and your partners may use all contact information provided to contact me regarding this application, loan offer, account status or future issues. You may utilize electronic, mobile, autodialed messages, SMS or traditional methods. I futher acknowledge and agree, that I will notify the creditor or prospective creditor in writing of any change in my name, address or employment within a responsible time thereafter.

Married Wisconsin Residents: No provision of any marital property agreement, a unilateral statement under Wis. Statute Section 766.59 or a court decree under Section 766.70 adversely affects the interest of the creditor unless the creditor, prior to the time the credit is granted, is furnished with a copy of the agreement, statement or decree or has actual knowledge of the adverse provision when the obligation to the creditor is incurred.
Electronic Signature:   Date: 9/20/2018
Type your legal name. MUST BE SIGNED BY APPLICANT.

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