Enter the legal name of the patient:
Provide the personal idenity information that matches the patient's
Enter the address of the primary borrower:
(MUST BE A VALID STREET ADDRESS NO P.O. BOXES)
Mailing Address (Optional)
Indicate the state the primary borrower has legal residence.
Legal State of Residence:
Time at Residence:
Approval and application status will be sent to the following.
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.
Include current living expense.
Enter (1) one personal reference below:
Enter current employment details.
Please select the category that best fits your needs: *
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 Consumer Acceptance Corp., 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 Consumer Acceptance Corp. and/or its Lender(s) and other 3rd Parties. This
express consent applies to each such telephone number that I(We) provide to Consumer
Acceptance Corp. 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.
I hereby acknowledge that I am over the age of eighteen
(18) years, and that all the information set forth in this credit statement is true,
accurate and complete full and complete disclosure thereof.
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 applies for credit. What this means for you: when you submit an
application, 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 authorize any holder of this application
or any person, firm or corporation requested to extend credit thereunder, (including
any employee or agent of any of them) to communicate with any person, firm or corporation
including my employer in respect of my credit worthiness, for the purpose of reviewing
the account, assessing potential increases to the credit, for the purpose of taking
collection action on the account, or for other legitimate purposes associated with
the account. I further authorize any holder of the Retail Installment Contract,
the creditor thereof, any Attorney, debt collector or collection agency communicating
any and all information concerning this application or debt to any credit reporting
agency or other creditor. I further acknowledge and agree, that I will notify the
creditor or prospective creditor in writing of any changes in my name, address,
phone numbers or employment within a reasonable time thereafter. I consent to receiving
autodialed and message calls and emails from us or our agents on any numbers or
emails provided on this application and on any provided in the future.