Financing

* Indicates Required Field

Credit Application
First Name: *
Last Name: *
Daytime Telephone Number *
Alternative Telephone Number
Mother's Maiden Name: *
Member Number: *
Social Security Number *
Birth date*:
Email *
Current Address *
Time at Address *
Rent/ Own/ Live with Relatives*
Monthly Rent/ Mortgage: *
Drivers License #: *
State of Drivers License Issue *

Employment Information
Current Employer: *
Position: *
Gross Monthly Income *
Time at Current Employer*
Employer Address *
Employer Phone # *
Other Income *
Source of Income*:
Bankruptcy y/n *
Date of Bankruptcy *
Bankruptcy Status *

Co-Applicant Information
First Name: *
Last Name: *
Daytime Telephone Number *
Alternative Telephone Number
Mother's Maiden Name: *
Member Number: *
Social Security Number *
Birth date*:
Email *
Current Address *
Time at Address *
Rent/ Own/ Live with Relatives*
Monthly Rent/ Mortgage: *
Drivers License #: *
State of Drivers License Issue *

Co-Applicant Employment Information
Current Employer: *
Position: *
Gross Monthly Income *
Time at Current Employer*
Employer Address *
Employer Phone # *
Other Income *
Source of Income*:
Bankruptcy y/n *
Date of Bankruptcy *
Bankruptcy Status *

Secured Loan (Optional) y/n
Home as Collateral? y/n
Home Value
Mortgage Balance
Credit Amount Requested
Date of Services


Authorization to Release Credit Information: By my signature, I authorize New MedCare (and/or authorized lenders)to run a credit report and verify the information that I have provided. I understand that New MedCare will be acting as Fee-based credit processing agent on my behalf and therefore does not approve, deny, set the rate and terms, guarantee loan approvals, or discriminate against anyone for any reason. As a part of this search, I fully understand my credit request may be presented to multiple credit issuing companies and/or search companies including (but not limited to) banks, finance companies, credit card issuers and affiliated partnership programs with various institutes. For these services I understand that I will be charged loan processing and closing fees which can normally add to between $5.00 and $29.00 to my monthly payment. Furthermore, while calculated monthly, I understand that the total amount of the fees will be added to my base loan amount requested and become a part of my principal balance. I agree to "Hold Harmless" New MedCare from any and all illegal actions that might be taken as a result of a disputed matter with my Service Provider or Vendor. Signature Date Co-Applicant Signature Date Fax all requests to (407) 374-1871
Comments

Comments and Questions
I would like to receive all calls and emails in Spanish. (Me gustaria recibir todos las llamadas y mensajes en español.)