HOME PROCEDURES COVERED HOW APF WORKS PROVIDERS SUPPORT

Secure Application
Loan Information
Please use numeric characters only. Omit dollar signs, commas, and decimal points.
Total Amount of Loan: $
Reason for Loan:
 
Service Information
State Services Performed: Doctor's Name (If known)
Applicant Information
As you would like it to appear on the account.
First Name: MI: Last Name: Mother's Maiden Name: Member/Account #:
You must be at least 18 years or older.
SSN: Date of Birth:
 -   -   /   / 
We'll use your e-mail address "only" to communicate with you about your application and/or account.
Email:
No Email
No P.O. Boxes. We are required to obtain your physical street address.
Current Address: City: State: Zip:

Please use numeric characters only. Omit dollar signs, commas, and decimal points.
Time at Current Address: Housing: Monthly Rent/Mortgage:
Years Months $
Home Phone: Alternate/Cell Phone: Drivers License State: Drivers License #:
Employer Information
Please use numeric characters only. Omit dollar signs, commas, and decimal points.
Employer Name: Position: Income:
Employer Address: City: State: Zip:
Business Phone: Time at Current Employer:
Years Months
Other Income: Source of Other Income:
Bankruptcy: If yes, when: Bankruptcy Status:
 / 
Complete below if applicant has moved or changed jobs in the last 2 years
Previous Home Address: City: State: Zip
Time at Previous Address:
Years Months
Previous Employer: Position: Time at Previous Employer:
Years Months
Previous Employer Address: City: State: Zip
Secured Loan (Optional)
If required, would you use your home as collateral?
If yes, please fill out the additional items below and if 2 people are listed on the house, please fill out cosigner information.
Estimated Property Value: Current Mortgage Balance:
Co-Applicant Information (Optional)
As you would like it to appear on the account.
Relationship to Applicant: First Name: MI: Last Name:
You must be at least 18 years or older.
SSN: Date of Birth:
 -   -   /   / 
We'll use your e-mail address "only" to communicate with you about your application and/or account.
Home Phone: Email:
No Email
No P.O. Boxes. We are required to obtain your physical street address.
Current Address: City: State: Zip:

Please use numeric characters only. Omit dollar signs, commas, and decimal points.
Time at Current Address: Housing: Monthly Rent/Mortgage:
Years Months
Employer Information
Please use numeric characters only. Omit dollar signs, commas, and decimal points.
Employer Name: Position: Income: Time at Current Employer:
Years Months
Business Phone:
Employer Address: City: State: Zip:
Other Income: Source of Other Income: Bankruptcy: If yes, when:
 / 
Complete below if coapplicant has moved or changed jobs in the last 2 years
Previous Home Address: City: State: Zip
Time at Previous Address:
Years Months
Previous Employer: Position: Time at Previous Employer:
Years Months
Previous Employer Address: City: State: Zip

AUTHORIZATION TO RELEASE CREDIT INFORMATION
By submitting your application, You agree to have APF, a loan processing company, search all options for the best possible loan offer. I fully understand that APF may be sending my credit request to companies such as (but not limited to) Banks, Finance Companies, Credit Card Issuers, and affiliated partnership program with "The Lending Tree" and other such companies.

HOME PROCEDURES COVERED HOW APF WORKS PROVIDERS SUPPORT
©2009 Advance Patient Financing Services. • All Rights Reserved. • Website by MosierData