Patient Financing Application
Credit Amount Requested


 Provider
Co Signer
First Name


 Middle Name

 Last Name

 Mother's Maiden Name
Social Security No.



 Date of Birth

 Email
Current Address


 City

 State


 Zip
Time at Current Address


 Own Home
Parents/Relatives
Rent
Other		 Monthly Rent/
Mortgage Payment
Would you be interested in a Home Equity Loan?
If yes, estimated property value:
 Current Mortgage Balance
Home Phone


 Alternative/Cell Phone
 Drivers License State and #
Current Employer


Position
 Gross Income
$
Week
Month
2-Weeks
Year
Employer Address
 City
 State

 Zip
Business Phone
 Time at current employer
Other Income
(Can include spouse)*
$

Source of other income
Have you ever declared bankruptcy?
If yes, when:
*You do not have to include alimony, child support, or separate maintenance income unless you want us to consider it as basis for repayment.
Complete only if you have moved or changed jobs
in the last two years:
Previous Address
 City
 State
 Zip
Time at previous address
Previous Employer
Position
Time at previous employer
Authorization to Release Credit Information and Credit Policies
By my signature, I authorize "Maximum Capital Corporation", and / or their affiliated lending partners to run a credit report and verify the information I have provided. I understand "Maximum Capital Corporation" will be acting as a Fee Based credit-processing affiliate 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" "Maximum Capital Corporation" from any and all legal actions that might be taken as a result of a disputed matter with my Service Provider or Vendor.
Electronic Signature of Applicant
Date