Hearing Aid Loan Program Application


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MED CENTRIC CREDIT, INC.

Hearing Aid Loan Program Application

Focused On Your Health

NOTICE TO APPLICANT: YOU MAY APPLY FOR CREDIT IN YOU R NAME ALONE WITHOUT YOUR SPOUSE OR ANY OTHER PERSON REGARDLESS OF YOUR SEX OR MARITAL STATUS. THE FEDERAL EQUAL CREDIT OPPORTUNITY ACT PROHIBITS CREDITORS FROM DISCRIMINATING AGAINST CREDIT APPLICANTS ON THE BASIS OF RACE, COLOR, RELIGION, NATIONAL ORIGIN, SEX, MARITAL STATUS, AGE (PROVIDED THE APPLICANT HAS THE CAPACITY TO ENTER INTO A BINDING CONTRACT), BECAUSE ALL OR PART OF THE APPLICANT'S INCOME IS DERIVED FROM PUBLIC ASSISTANCE PROGRAM OR BECAUSE THE APPLICATION HAS IN GOOD FAITH EXERCISED ANY RIGHTS UNDER THE CONSUMER PROTECTION ACT. THE FEDERAL AGENCY THAT ADMINISTERS THIS LAW IS THE FEDERAL TRADE COMMISSION EQUAL CREDIT OPPORTUNITY, WASHINGTON, DC 20850.

First Name

M. I.

Personal Information

Physical Street Address (No P.O. Boxes) Apt./Unit

Telephone Number

ID Type: State Drivers License State Issued ID

State

ZIP Code

Country

City

State

ZIP Code

Country

Social Security Number

Employment Status Non-Resident Alien

Resident Alien

City

E-Mail Address

Home: Cell:

Citizenship: U.S. Citizen

State Law Notices

Apt./Unit

Mailing Street Address, (If different)

Employed

U.S. Passport US Military ID

Self-Employed

Unemployed

Date of Birth

Gross Annual Income Retired

Expiration (dd/mm/yyyy) State or Issuer

$__ __ __,__ __ __.00 USD Identification Number

CALIFORNIA RESIDENTS: If you are married you may apply for a separate account. NEW JERSEY RESIDENTS: Certain provisions of this agreement are subject to applicable law. As a result they may be void, unenforceable or inapplicable in some jurisdictions. None of these provisions however is void, unenforceable or inappropriate in New Jersey. OHIO RESIDENTS: The Ohio law against discrimination requires that all creditors make credit equally available to all creditworthy customers and that credit reporting agencies maintain separate credit histories on each individual upon request. The Ohio Civil Rights Commission administers compliance with this law. TENNESSEE RESIDENTS: This agreement will not become affective unless and until creditor has (1) provided the disclosures required pursuant to the Federal Truth in Lending Act to you and (2) the creditor extends credit to you. WISCONSIN RESIDENTS ONLY: No marital property agreement, unilateral statement or court decree adversely affects the creditors rights, unless you provide the creditor a copy of such agreement, statement or court order before being granted credit, or creditor has actual knowledge of its terms before your account is opened.

Signature For Wisconsin Residents Only

Signatures

Suffix

Last Name

Date

Notice: Proposed creditors may gather information about you, including from your employer, your bank, credit bureaus and others to verify your identity and determine your eligibility for credit, renewal of credit, and future extensions of credit. If you request the information, the creditor will tell you whether or not the creditor requested a credit bureau report and the names and addresses of any credit bureaus that provided the creditor with such reports. You do represent and state that the information listed on this application is true and complete. You authorize us and any proposed creditors to verify you credit standing and employment as necessary. Date

Applicant Signature

MED CENTRIC CREDIT, INC. Focused On Your Health