Index

This will not affect your credit score

How would you rate your credit? *

Average or Above / 640+

Below Average / Less Than 640

Have you declared bankruptcy in the last 3 years? * YES NO

Are you a US citizen? *
YES NO

Service Provider/Merchant Name

Service Provider Phone No

First Name *

Middle Name

Last Name *

Social Security Number *

Date of Birth *

Email *

Home Address *

City *

State *

Zip Code *

Do you Own/Rent/Other

Monthly Payment

How long have you lived there?

Number of your Employer

Your Position

Employers Phone:

Area Code & Phone Number *

Gross Monthly Income *

Any other source of income ?

Amount of Other Income

Amount to finance *

Mother's Maiden Name

Driver's License Number

Total Price of Procedure

Representative Number

By checking the box below, you hereby authorize CredTek and/or our Affiliated companies to run your credit and verify the information you have provided. You fully understand that CredTek and our affiliated companies do not approve, deny, or extend credit in any form. Furthermore, you authorize a Representative with our affiliated companies to contact you and/or text you at the number you have listed for the purpose of processing your request.
By checking I Agree checkbox, you are agreeing to the application terms as shown.*

I Agree

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