ION LIFE

Credit Application

Procedure Information 
Product:
     
Applicant Information
First Name:
Middle Initial:
Last Name:
Suffix:
Social Security#:
Driver License#:
Date of Birth: (MM/DD/YYYY)
   
Applicant Contact Information
Home Address: (incl. apt#)
Address Line 2:
City:
State:
ZIP:
Time There: years months
Rent/Mortgage Payment: $ (no commas)
Rent/Buy/Own:
Home Phone:
Business Phone:
E-mail Address:
   
Previous Address: (if less than 3 years at current)
City:
State:
ZIP:
Time There: years months
   
Nearest Relative or Personal Reference
Name: (other than co-applicant, not living with you)
Phone:
   
Applicant Income Information
Employer:
Time There: years months
Position: Self-employed Retired Student
Homemaker Active Military - Rank:
Your Monthly Salary: $ (no commas)
Other Income*: $   Source:
* Alimony, Child Support, or Separate Maintenance income need not be revealed if you do not wish it considered as a basis for repayment.
Previous Employer: (if less than 2 years at current)
Previous Position:
Time There: years months
Bank Accounts: Checking Savings
   
Co-Applicant Information
First Name:
Middle Initial:
Last Name:
Social Security Number:
Driver License Number:
Date of Birth: (MM/DD/YYYY)
   
Co-Applicant Contact Information
Street and Number:
City:
State:
ZIP:
Time There: years months
Rent/Buy/Own:
Home Phone:
Monthly Rent/Mortgage: $ (no commas)
E-mail Address:
Relationship to Applicant:
 
Co-Applicant Income Information
Employer:
Phone:
Time There: years months
Position: Self-employed Retired Student
Homemaker Active Military - Rank:
Your Monthly Salary: $ (no commas)
Other Income: $ Source:
   
 
Loan Information
Amount Requested: $ (no commas)
   
Provider Information
Provider ID#: LIFE123
Provider Name: IONLIFE
Wholesaler: (if other than applicant. if applicant, put "self")
Office Phone#:
Office Fax#:
E-mail Address:
 
Anything else you want us to know
Notes:


READ BEFORE SUBMITTING APPLICATION

By submitting this application I have verified that all information submitted on this application is true and correct to the best of my knowledge, as well as allowing American Benefit Credit, Inc and/or its lender(s)or assigns to verify the enclosed information, including, but not limited to obtaining my credit report, contacting my employer to verify employment and income, and/or contacting my Provider to verify the type of procedure(s), procedure date, deposit amount, procedure amount, product, sales price and remit payment upon approval. I understand and agree that the Lenders (as defined in the Promissory Note or communicated to me) can furnish information concerning my account to consumer reporting agencies and others who may properly receive that information. Furthermore, I am signing that a Provider’s staff member may submit on my behalf and that I have read the disclosure and agree to the conditions set forth. I also agree that this application and any information I submitted with it may be forwarded to other creditors. American Benefit Credit, Inc. or other creditors, will provide me any required disclosures from such other creditors. By signing below, I further agree that such other creditors may obtain a credit report and use it in making a credit decision.
 

 I acknowledge that I have read and agree to the above terms and conditions and that I had the opportunity to print, for my files, a copy of the terms that will govern my account.  





To check the status of the application go to www.enhancepatientfinance.com – Click on "DOCTOR" – Click on "Submit an Application" – Click on "Check Status" of an application – enter the application number and the applicant's zip code

Enhance Patient Financing, Inc
Premier Program
877-436-4262 Phone
760-579-0303 Fax