Treatment Financing Application

Please complete the form below.

Personal Identification:

First Name *

Last Name *

Date of Birth *

Last 4 Digits of Social *

Front of Drivers License *

Front of Drivers License

Back of Drivers License *

Back of Drivers License

Contact Information:

Phone *

Email *

Home Address *

Employment and Income:

Employment Status *

Employed

Self-Employed

Unemployed

Employer Name (if employed) *

Employer Phone *

Annual Income *

Loan Specifics:

Desired Loan Amount *

Purpose of the Loan *

Assisting Bodcor Team Member:

Assisting Bodcor Team Member *

Electronic Signature Consent:

By selecting the check-box below, I agree to use electronic records and signatures.

Electronic Signature Disclosure Agreement *

Acknowledgement of my consent.

Information Collection:

We collect personal identification, contact information, employment and income details, and financial information solely for the purpose of evaluating your eligibility for our financing options.

Use of Information:

The information you provide will be used to assess your creditworthiness, process your application, and manage your account. We may also use your contact information to communicate with you regarding your application and our services.

Sharing of Information:

We do not sell, rent, or lease your personal information to third parties. Your information may be shared with credit bureaus and financial institutions as necessary to process your application and provide financing services.

Consent:

By submitting your financing application, you consent to the collection, use, and sharing of your information as described in this Privacy Policy.

Changes to Policy:

We reserve the right to modify this policy at any time. Any changes will be promptly updated on our website.

Treatment Financing Application

Treatment Financing Application

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