Enter the legal name of the primary borrower:
Provide the personal idenity information that matches the primary borrower's name above.
Enter the address of the primary borrower:
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 Monthly values.
Include current living expense.
Enter current employment details.
Service Provider Signature
Electronically sign credit sale application:
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.