Home Doctors FAQs Contact
  

Canadian Citizens Please Apply Here
All appropriate fields required for successful financing.
Loan Amount
$ 		Patient Name

(leave blank if the same as credit applicant below)		 Procedure Type
Doctor or Clinic Name
 Doctor or Clinic Phone
 Surgery Date
 /  / 
Credit Applicant

First Name
  

Middle Initial


Last Name
 

Email Address
Social Security #
 Home Phone
 Cell Phone
Current Address (no PO Boxes)
 City
 State
 Zip
 Date of Birth
 /   / 
Time at Current Address
Years Months 		Housing
Monthly Rent/Mortgage
$
Current Employer
 Position
 Annual Gross Income (income before taxes)
$ 		OR Monthly Gross Income (income before taxes)
$
Time at Current Employer
Years Months 		    
Business Phone
 Employer Address
 City
 State
 Zip
Other Income Annual (include spouse)
$ / year		 Source of Other Income
     
Co-Signer
First Name
 Middle Initial
Last Name
 
Email Address
Social Security #
 Relationship to Patient / Applicant
Current Address (no PO Boxes)
 City
 State
 Zip
 Date of Birth
 /   / 
Home Phone
- - 		Time at Current Address
Years Months 		Housing
Monthly Rent/Mortgage
$
Current Employer
 Position
 Time at Current Employer
Years Months
Employer Phone
- - 		Annual Income (income before taxes) 
$ / year		 OR Monthly Income (income before taxes)
$   / month
Current Employer Address
 City
 State
 Zip
All appropriate fields required for successful financing.

By submitting this application I have verified that all information submitted on this application is true and correct to the best of my knowledge, as well as allowing CITERRA FINANCIAL and/or its Lender(s) to verify the enclosed information, including, but not limited to, obtaining my credit report, contacting my employer to verify employment and income, and/or contacting my Physician to verify the type of procedure(s), procedure date, deposit amount, procedure amount and remit payment on approval.
 


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