HTTP VS HTTPS: The 'S' at the end of HTTPS stands for 'Secure'. It means all communications between your browser and the website are encrypted. HTTPS is often used to protect highly confidential online transactions like online banking and online credit applications like this form.
Service Provider
*
Provider City & State
*
Describe Procedure
*
Amount
*
Credit Applicants Name
*
Patient Name
*
D.O.B. (Month - Day - Year)
*
-
-
Date Picker Icon
Social Security
*
Address
*
Street Address Line 2
State / Province
Years at this address
*
Own or Rent
*
Monthly Payment
*
Email
*
Mobile Phone (with Area Code)
*
Drivers License #
*
Expected Gross Income This Year
*
Job Title
*
Years at Job
*
Employer Name
*
Employer Phone # (with area code)
*
Employer Address
*
Street Address Line 2
State / Province
US Citizen
*
Yes
No
Mothers Maiden Name
*
Married
*
Yes
No
Spouse's Name
*
Spouse's Phone #
*
Reference Name
*
Reference Phone
*
*
By submitting this application I agree to the following. I agree and consent to electronic communications. I Agree and authorize AFT Capital and its lending partners to forward my application for review and acceptance of applying for credit. I hereby acknowledge and recognize this is an application for credit.
Electronic Signature: Type your legal name. Must be signed by applicant:
*
Submit
Should be Empty: