Medical Loan Finance Company Financing Medical Procedures

DO NOT USE DECIMALS ON ANY DOLLAR AMOUNT

Loan Information

Total Amount of Loan:	Reason for Loan:
$

Credit Information

Your Credit:		Co-Applicant Credit:
Excellent - 700 Credit Score or better Good - 650 to 699 Credit Score Fair - 630 to 649 Credit Score Poor- 600 to 629 Credit Score

Service Information

Provider Name:

James Rieger NO DISCOVER

Applicant Information

First Name:	MI:	Last Name:	Mother's Maiden Name:

SSN:	Date of Birth:
- -	/ /

Email:

No Email

Current Address: (Cannot contain PO Box)

City:	State:	Zip:

Time at Current Address:

Years Months

Housing:	Monthly Rent/Mortgage: Numbers only (e.g. 1000)
	$

Estimated Property Value:	Current Mortgage Balance:

Home Phone:	Alternate/Cell Phone:

Drivers License State:	Drivers License #:

Employer Information

Employer Name:	Position:	Income: Numbers only (e.g. 35000)

Employer Address:

City:	State:	Zip:

Time at Current Employer:

Years Months

Business Phone:

Other Income: Numbers only (e.g. 35000)	Source of Other Income:

Co-Applicant Information (Not Required)

First Name:	MI:	Last Name:	Relationship to Applicant:

SSN:	Date of Birth:
- -	/ /
Email:	Mother's Maiden Name:
No Email

Current Address:
Copy Applicant Address

City:	State:	Zip:

Time at Current Address:

Years Months

Housing:	Monthly Rent/Mortgage:

Home Phone:	Alternate/Cell Phone:

Drivers License State:	Drivers License #:

Employer Information

Employer Name:	Position:	Income:

Employer Address:

City:	State:	Zip:

Time at Current Employer:

Years Months

Business Phone:

Other Income:	Source of Other Income:

Secured Loan (Optional)

If required, would you use your home as collateral?

If yes, please fill out the Estimated Property Value and Current Mortgage Balance fields and if 2 people are listed on the house, please fill out Co-Applicant information.

AUTHORIZATION TO RELEASE CREDIT INFORMATION AND CREDIT POLICIES
By submitting my application, I authorize "Med Loan Finance", a loan processing company and / or their affiliated lending partners to run a credit report and verify the information I have provided. I understand "Med Loan Finance" will be acting as a 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 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" "Med Loan Finance" from any and all legal actions that might be taken as a result of a disputed matter with my Service Provider or Vendor.