Why Finance?

Please take a minute to answer the following questions to help you determine your eligibility for financing. If there is a co-applicant, you must provide all co-applicant information, in addition to applicant information. If you have any questions, please call toll free 1.800.358.8980.

All information is strictly confidential and will be used by Medical Resource Partners and/or its lenders for the purpose of eligibility determination. By submitting this application you authorize Medical Resource Partners and its agents to obtain any credit reports and information they deem necessary to complete a credit review.

IMPORTANT: You will see the terms and conditions at the end of this page. You MUST approve the terms and conditions for the application to be complete. If you have not clicked 'YES' on the terms and conditions section, you have not completed the application. Please follow the directions carefully as you go through the process. Thank you for applying!
Applicant Information
First Name Last Name
Address City
State   Zip Phone
Email    
Date of Birth
(mm/dd/yyyy) 		SSN
Driver Lic. # Expires
(mm/dd/yyyy)
   
Do you have a minimum of two years established credit and none of the following in the past three years: foreclosures or repossessions, bankruptcies, tax liens or civil judgments? Yes No
Do you have any of the following delinquencies: charged-off accounts; unpaid collection accounts; late payments exceeding 60 days? Yes No
Are you currently enrolled in a consumer credit-counseling program? Yes No
   
Applicant Employer Information
Employer Occupation
Phone Employment Length Years Months
Gross Monthly
Salary 		   
Additional Information
Home Information
Own Rent
Other  
Length at Residence Years Months
Monthly Payment Other Income
Co-Applicant Information (if applicable)
First Name Last Name
Address City
State   Zip Phone
Date of Birth
(mm/dd/yyyy)		 SSN
Driver Lic. # Expires
(mm/dd/yyyy)
Co-Applicant Employer Information
Employer Occupation
Phone Employment Length Years Months
Gross Monthly Salary    
Co-Applicants Additional Information
Home Information
Own Rent
Other  
Length at Residence Years Months
Monthly Payment Other Income
Procedure Information
Type of Procedure Doctor
Procedure Cost Doctor Phone
 
Terms and Conditions
All the information on this form is complete, correct and provided to Medical Resource Partners and its agents to obtain an installment loan or credit loan. I/we authorize Medical Resource Partners to investigate credit and employment history and to report the credit experience of any party or authorized user to consumer reporting agencies and others. I/we understand that Medical Resource Partners will retain this application whether or not it is approved. I/we understand that if the application is for a secured loan by real property that additional information is required. I/we certify that I am/we are 18 years or older and have completed the application questions accurately at any time after this application and/or during my/our relationship with Medical Resource Partners. I/we authorize Medical Resource Partners to obtain information concerning my/our employment and credit standing and authorize my/our employer, banks and/or other listed references to release information to Medical Resource Partners. Medical Resource Partners may review from time to time my/our eligibility for any credit extended on the account and may provide information about me/us to others. If I/we designate other authorized users, credit bureaus may receive account information on the authorized users in each user's name. I/we agree to notify Medical Resource Partners immediately upon any material change in the information I/we provided herein.

I/we affirm that each of the answers given to the foregoing questions is true and correct and that the foregoing is a true and correct statement of my/our financial condition. It is a federal criminal offense to knowingly make any false statement or report, or to willfully overvalue any property for the purpose of influencing Medical Resource Partners to act on this application.

I/we understand and agree to the terms and conditions of this application:
 
Applications submitted after 5pm EST will be processed on the next business day.
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