| *First
Name of person applying for the surgical, medical or dental
procedure loan (the applicant). |
|
| Middle
Initial |
|
| *Last
Name: |
|
| *Applicant's
Email Address |
|
| Overseas
Doctor, Clinic or Hospital Name (if you know it):
|
|
| *Application
Type |
This is my first time
I am reapplying
|
| *Applicants
Employment Status |
|
| If
you checked other please describe. |
|
| Check
Yes or No - I have a co-signer |
YES
NO
|
| Co-signers
Employment Status |
|
| If
you checked other please describe. |
|
| Date
of Procedure |
|
| Name
of Company you are using to plan your procedure overseas.
|
Medical Tours International (MTI)| REGENECELL
|
| Please
enter the amount (in US dollars) you wish to finance:
|
|
| If
you are a parent or guardian of the patient please tell us
the patients First Name. |
|
| Parent
or Guardians Middle Initial |
|
| Parent
or Guardians Last Name |
|
| Your
E-mail Address |
|
| *Applicants
Date of Birth Month/Day/Year |
|
| *Applicants
social security number |
|
| *Applicants
Home Phone with area code |
|
| Applicants
Work Phone with area code and ext. |
|
| Applicants
Mobile Phone with area code |
|
| *Applicants
Marital Status |
Married
Single
Widowed
Divorced
Separated
Other
|
| If
you checked other please describe |
|
| *Check
which one applies to the applicants home ownership
|
Own
Rent
Military
Live with parents
Home is paid off
Live with fiance
other
|
| If
you checked other please describe |
|
| *What
is your monthly Rent/Mortgage? |
|
| *How
long have you lived at this residence? |
|
| *Street
|
|
| *City
|
|
| *Zip
Code |
|
| *Country
|
|
| Telephone
Number w/Area Code |
|
| *Check
one - Your Occupation |
|
| If
you check other occupation please describe |
|
| Your
Employer or Company Name |
|
| Employers
Street Address |
|
| State/Province
|
|
| Zip
Code |
|
| Country
|
|
| What
is your verifiable Gross salary before taxes per month?
|
|
| How
long have you worked at this job? |
|
| What
is your spouses verifiable Gross monthly income before taxes?
|
|
| If
you receive retirement or pension income how much do you receive
a month? |
|
| If
you receive child support or maintainance and wish to include
it please tell us what those monthly payments are.
|
|
| If
you have other income from work and would like to include
that please tell us how much it is monthly |
|
| First
Name of your co-signer if you have a co-signer |
|
| Middle
Initial |
|
| Last
Name |
|
| What
is their relationship to you? |
|
| If
you checked other please describe your relationship to the
co-signer |
|
| Co-signers
email address |
|
| Co-signers
date of Birth Month/Day/Year |
|
| Co-signers
social security number |
|
| Co-signers
Street Address |
|
| Co-signers
City or Town |
|
| Co-signers
State/Province |
|
| Co-signers
Zip Code |
|
| Co-signers
country |
|
| Co-signers
Home phone/with area code |
|
| Co-signers
mobile phone/with area code |
|
| Go-signers
work phone/with area code |
|
| Co-signers
Marital Status- check one |
|
| Of
you checked other please describe |
|
| Check
one. Co-signers Employment Status |
|
| If
you checked other please describe |
|
| Co-signers
employer or company name |
|
| Employers
Street Address |
|
| City/Province
|
|
| Zip
Code |
|
| Country
|
|
| Co-signers
Monthly Rent or Mortgage |
|
| Co-signers
Gross Monthly Income before taxes. |
|
| If
there is any other income co-signer wishes to list please
describe monthly amount and source |
|
| What
is your anticipated date for travel and surgery?
|
|
| 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 the lender 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. |
YES
|
| I
understand and agree that the Lender(s) (as defined in the
Promissory Note or communication to me) can furnish information
concerning my account to consumer reporting agencies and others
who may properly receive that information. |
YES
|
| Furthermore,
I am signing that Physician staff may apply on my behalf.
If I have included the information of a co-applicant, I have
done so with his/her full authority and hereby direct that
this company and/or its Lenders may investigate his/her credit.
I have read this disclosure and agree to all terms set forth.
|
YES
|
| Check
that you understand that Medical Tours International will
receive the funds and under agreement with REGENECELL, the
provider, will transfer the fees due to REGENECELL.
|
YES
|
| By
checking YES you agree that you are the applicant
|
YES
|
| Enter
any questions you have here or click Submit and we will respond
as soon as we receive your information. |
|
|
|
.
