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New Credit Application
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DO NOT USE DECIMALS ON ANY DOLLAR AMOUNT
Loan Information
Total Amount of Loan:
Reason for Loan:
$
Medical Procedure
Credit Information
Your Credit:
Select One...
Excellent
Good
Fair
Poor
Limited/Bad/No Credit
Co-Applicant Credit:
Select One...
Excellent
Good
Fair
Poor
Limited/Bad/No 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:
Janet Pearl
Applicant Information
First Name:
MI:
Last Name:
Mother's Maiden Name:
[Suffix]
Jr.
Sr.
I
II
III
IV
V
VI
SSN:
Date of Birth:
-
-
/
/
Email:
No Email
Current Address:
(Cannot contain PO Box)
City:
State:
Zip:
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Time at Current Address:
Years
Months
Housing:
Monthly Rent/Mortgage:
Numbers only (e.g. 1000)
Own House
Own Manufactured Home
Own Other
Rent
Parents/Family
House Paid Off
Other
$
Estimated Property Value:
Current Mortgage Balance:
Home Phone:
Alternate/Cell Phone:
Drivers License State:
Drivers License #:
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Complete below if applicant has moved in the last 2 years
Previous Home Address:
City:
State:
Zip
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Time at Previous Address:
Years
Months
Employer Information
Employer Name:
Position:
Income:
Numbers only (e.g. 35000)
[Select A Position]
Unemployed-With Income
Unemployed-No Income
Trades
Student
Service
Semi-Professional
Sales
Retired/Permanently Disabled
Professional
Production Worker
Owner Business Enterprise
Outside Worker
Office/Factory/OS Manager
Office Staff
Miscellaneous
Military-Officer
Military-Enlisted/NCO
Laborer
Homemaker
Guard (Civil & Postal Worker)
Executive
Driver
Creative
Yearly
Monthly
Weekly
Employer Address:
City:
State:
Zip:
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Time at Current Employer:
Years
Months
Business Phone:
Other Income:
Numbers only (e.g. 35000)
Source of Other Income:
Yearly
Monthly
Weekly
Complete below if applicant has changed jobs in the last 2 years
Previous Employer:
Position:
[Select A Position]
Unemployed-With Income
Unemployed-No Income
Trades
Student
Service
Semi-Professional
Sales
Retired/Permanently Disabled
Professional
Production Worker
Owner Business Enterprise
Outside Worker
Office/Factory/OS Manager
Office Staff
Miscellaneous
Military-Officer
Military-Enlisted/NCO
Laborer
Homemaker
Guard (Civil & Postal Worker)
Executive
Driver
Creative
Previous Employer Address:
City:
State:
Zip
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Time at Previous Employer:
Years
Months
Co-Applicant Information (Not Required)
First Name:
MI:
Last Name:
Relationship to Applicant:
[Suffix]
Jr.
Sr.
I
II
III
IV
V
VI
Spouse
Mother
Father
Sister
Brother
Son
Daughter
Fiance
Other
SSN:
Date of Birth:
-
-
/
/
Email:
Mother's Maiden Name:
No Email
Current Address:
Copy Applicant Address
City:
State:
Zip:
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Time at Current Address:
Years
Months
Housing:
Monthly Rent/Mortgage:
Own House
Own Manufactured Home
Own Other
Rent
Parents/Family
House Paid Off
Other
Home Phone:
Alternate/Cell Phone:
Drivers License State:
Drivers License #:
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Complete below if Co-applicant has moved in the last 2 years
Previous Home Address:
City:
State:
Zip
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Time at Previous Address:
Years
Months
Employer Information
Employer Name:
Position:
Income:
[Select A Position]
Unemployed-With Income
Unemployed-No Income
Trades
Student
Service
Semi-Professional
Sales
Retired/Permanently Disabled
Professional
Production Worker
Owner Business Enterprise
Outside Worker
Office/Factory/OS Manager
Office Staff
Miscellaneous
Military-Officer
Military-Enlisted/NCO
Laborer
Homemaker
Guard (Civil & Postal Worker)
Executive
Driver
Creative
Yearly
Monthly
Weekly
Employer Address:
City:
State:
Zip:
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Time at Current Employer:
Years
Months
Business Phone:
Other Income:
Source of Other Income:
Yearly
Monthly
Weekly
Complete below if Co-applicant has changed jobs in the last 2 years
Previous Employer:
Position:
[Select A Position]
Unemployed-With Income
Unemployed-No Income
Trades
Student
Service
Semi-Professional
Sales
Retired/Permanently Disabled
Professional
Production Worker
Owner Business Enterprise
Outside Worker
Office/Factory/OS Manager
Office Staff
Miscellaneous
Military-Officer
Military-Enlisted/NCO
Laborer
Homemaker
Guard (Civil & Postal Worker)
Executive
Driver
Creative
Previous Employer Address:
City:
State:
Zip
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Time at Previous Employer:
Years
Months
Secured Loan (Optional)
If required, would you use your home as collateral?
No
Yes
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.
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