Credit Application
Personal Information
Loan Amount    

Personal Information
 Enter the legal name of the primary borrower:
First Name:   Last Name:   Middle:
 Provide the personal idenity information that matches the primary borrower's name above.
Social Security Number:             Date of Birth:      
Marital Status:  
 Enter the address of the primary borrower:
Street Address:     Apt:
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 Monthly values.
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.

Work History
Enter current employment details.
Employment Status:  

Service Provider Signature
Surgery Date:  
Electronically sign credit sale application:
Authorized Agent for Service Provider:   Title:  

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.