Credit Application

Please fill out and submit the application below. One of our Patient Coordinators will contact you shortly to discuss your financing options, or for immediate assistance call 888-763-LIPO (5476). **ALL Applicant and Employer Information must be filled out completely in order to be processed.
Loan Information
Total Amount of Loan?:   A value is required.
What procedures would you like to finance?:   A value is required.
Applicant Information
First Name:   A value is required.
Last Name:   A value is required.
Middle Name:   A value is required.
Mothers Maiden Name:   A value is required.
Social Security #:   A value is required.
Date of Birth (month, day, year):   A value is required.
Email Address:   A value is required.
Current Address:   A value is required.
City:   A value is required.
State:   A value is required.	Zip:   A value is required.
Time At Current Address: Years   A value is required. Months   A value is required.
Housing:   Own House Own Manufactuered Home Own Other Rent Parents Other	Monthly Rent/Mortgage:   A value is required.
Phone:   A value is required.
Alternate Phone:   A value is required.
Complete below if applicant has moved in the last 2 years
Previous Address:
City:
State:	Zip:
Time At Previous Address: Years   Months
Employer Information
Employer Name:   A value is required.
Position:   A value is required.
Income:   A value is required.	Payment Schedule:   Yearly Monthly Bi-Weekly Weekly
Employer Address:   A value is required.
City:   A value is required.
State:   A value is required.	Zip:   A value is required.
Time At Current Employer: Years   A value is required. Months   A value is required.
Business Phone:   A value is required.
Other Income:	Source of Other Income:
Complete below if applicant has changed jobs in the last 2 years
Previous Employer Address:
City:
State:	Zip:
Time At Previous Employer: Years   Months
Business Phone:
Co-Applicant Information (Not Required)
First Name:
Last Name:
Middle Name:
Relationship To Applicant:
Social Security #:
Date of Birth (month, day, year):
Current Address:
City:
State:	Zip:
Time At Current Address: Years   Months
Housing:   Own House Own Manufactuered Home Own Other Rent Parents Other	Monthly Rent/Mortgage:
Phone:
Estimated Property Value:
Current Mortgage Balance:
Driver's License State:	Driver's License #:
Complete below if Co-applicant has moved in the last 2 years
Previous Address:
City:
State:	Zip:
Time At Previous Address: Years   Months
AUTHORIZATION TO RELEASE CREDIT INFORMATION AND POLICIES
By my signature, I authorize "Adora Clinic" to submit to a loan processing company to run a credit report and verify the information I have provided. I understand "Adora Clinic" will be acting as my credit-processing agent 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 partnership programs with other such affiliated companies. I understand that I will be charged loan processing fees for these services. 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 in most cases. I agree to "hold harmless" "Adora Clinic" from any and all legal actions that might be taken as a result of a disputed matter with my Service Provider or Vendor.
Please Print Your Name:   A value is required.
I Agree Please make a selection.