Credit Application

Identity Verification: To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. As a result, under our customer identification program, we must ask for your name, street address, mailing address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver’s license or other identifying documents.

Loan 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:      
 Enter the address of the primary borrower: (MUST BE A VALID STREET ADDRESS NO P.O. BOXES)
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: Other source of Income and amount. Please note, such income need not be revealed if the applicant does not want the creditor to consider it in determining the applicant's creditworthiness.

 Enter all amounts as Monthly values.
Gross Monthly Salary:  
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.

Enter (1) one personal reference below:          
Name:   Phone: ( )   -       Relationship:  

Work History
Enter current employment details.
Employment Status:  

Product/Service Information
I Agree    

Please select the category that best fits your needs: *
Product/Services Type:  
Select Product(s) or Service(s): *


Please read before Continuing.

To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. What this means for you: When you open an account, we will ask for your name, address, date of birth and other information that will allow us to identify you. We may also ask to see your driver’s license or other identifying documents.

I HEREBY ACKNOWLEDGE that I am over the age of eighteen (18) years, I am a United States citizan or permant resident and that all of the information set forth in this credit statement is true, accurate and full and complete disclosure thereof. I am providing written consent under the Fair Credit Reporting Act for above client and its partners with whom I am matched to obtain a consumer credit report from a contracted credit bureau. I understand that I am submitting an application for credit, and am consenting to the use of my credit report information. I authorize any holder of this credit application or any person, firm or corporation requested to extend credit there under, (including any employee or agent of any of them) to communicate with my employer in order to verify my employment. I authorize any holder of the Retail Installation Contract, the creditor thereof, or any Attorney, debt collector or collection agency to communicating any and all information concerning this application or debt to any credit reporting agency or other creditor. By providing my email address, I consent to receive electronic information such as monthly billing reminders, statements and collection notices. I also acknowledge that you and your partners may use all contact information provided to contact me regarding this application, loan offer, account status or future issues. You may utilize electronic, mobile, autodialed messages, SMS or traditional methods. I futher acknowledge and agree, that I will notify the creditor or prospective creditor in writing of any change in my name, address or employment within a responsible time thereafter.

Married Wisconsin Residents: No provision of any marital property agreement, a unilateral statement under Wis. Statute Section 766.59 or a court decree under Section 766.70 adversely affects the interest of the creditor unless the creditor, prior to the time the credit is granted, is furnished with a copy of the agreement, statement or decree or has actual knowledge of the adverse provision when the obligation to the creditor is incurred.


You agree and consent to receive electronically all communications, agreements, documents, notices, and disclosures (collectively, Communications) that we provide in connection with funding and the servicing of your payment obligations under the funding terms you agree to with us; and Communications include, as applicable:

  • Communications about your funding application, your funding rate, and your final terms
  • Communications about your backer account including payments in and out of your backer account, offers, note purchases, and other
  • Terms and conditions and policies you agree to, including updates to these agreements or policies
  • Initial or periodic disclosures
  • Payment receipts
  • Notices of default
  • Federal and state tax statements we are required to make available to you
  • Any other information relating to your payments to us

We will provide these Communications to you by emailing them to you at your registered email address. It is your responsibility to keep your registered email address up to date so that we can communicate with you electronically.

In order to access and retain electronic Communications, you will need: a computer with an Internet connection; a current web browser that includes 128-bit encryption and with cookies enabled (e.g. Internet Explorer version 6.0 and above, Firefox version 2.0 and above, Chrome version 3.0 and above, or Safari 3.0 and above); a valid email address; and sufficient storage space to save past Communications or an installed printer to print them. You confirm that you have access to the necessary equipment and software to receive and save/print our Communications to you.

You may withdraw your consent to receive Communications electronically by:

Our regular business hours are
9:00am to 5:00pm PST
888 - 502 -8027
Address for Regular Mail
15303 Ventura Blvd. Suite 850
Sherman Oaks, CA 91403

[]  By checking this box (1) you authorize to forward your application, including your nonpublic personal information, to other companies for consideration of your qualification for a loan product; (2) you consent that we may share the information you provide to us with other companies to receive products or services we believe may be of interest to you; and (3) you acknowledge you have reviewed our Privacy Policy which can found at (4) you acknowledge you have reveiwed and agreed to our Terms of Use which can be found at

Electronic Signature Agreement. By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept" you consent to be legally bound by this Agreement's terms and conditions. You further agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action, or to otherwise provide, or in accessing or making any transaction regarding any agreement, acknowledgement, consent terms, disclosures or conditions constitutes your signature (hereafter referred to as "E-Signature"), acceptance and agreement as if actually signed by you in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature or any resulting contract between you and You also represent that you are authorized to enter into this Agreement for all persons who own or are authorized to access any of your accounts and that such persons will be bound by the terms of this Agreement. You further agree that each use of your E-Signature in obtaining a service constitutes your agreement to be bound by the terms and conditions of the Disclosures and Agreements as they exist on the date of your E-Signature.

Electronic Signature:   Date: 11/25/2015
Type your legal name. MUST BE SIGNED BY APPLICANT.

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, 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 and/or its Lender(s) and other 3rd Parties. This express consent applies to each such telephone number that I(We) provide to 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.